Healthcare Provider Details

I. General information

NPI: 1942661525
Provider Name (Legal Business Name): LISA MARIE MCDONALD FORTUNE P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 05/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3311 BEACH BLVD
JACKSONVILLE FL
32207-3704
US

IV. Provider business mailing address

6273 BROOKS CIR N
JACKSONVILLE FL
32211-7510
US

V. Phone/Fax

Practice location:
  • Phone: 904-396-1462
  • Fax: 904-396-1199
Mailing address:
  • Phone: 904-482-8795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT16461
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: