Healthcare Provider Details

I. General information

NPI: 1326804220
Provider Name (Legal Business Name): AMANDA CARRIE GLEASON FORTNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2024
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 SOUTH AVE
LA CROSSE WI
54601-5467
US

IV. Provider business mailing address

1900 SOUTH AVE
LA CROSSE WI
54601-5467
US

V. Phone/Fax

Practice location:
  • Phone: 970-248-2263
  • Fax:
Mailing address:
  • Phone: 719-569-9580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: