MEDICARE: BROOKE FORTNER DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1417732975
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BROOKE FORTNER DPT

Provider Business Mailing Address
First Line	:	1512 E 12TH AVE UNIT 206
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33605-3548
Country	:	US
Telephone Number	:	305-975-3594
Fax Number	:

Provider Business Practice Location Address
First Line	:	1512 E 12TH AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33605-3516
Country	:	US
Telephone Number	:	305-975-3594
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2023
Last Update Date	:	08/31/2023

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Directions to “ BROOKE FORTNER DPT” Practice Location

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