Provider Demographics
NPI:1649442120
Name:FORTIN, ANGELINA MARIE (LPTA, ATC)
Entity type:Individual
Prefix:MRS
First Name:ANGELINA
Middle Name:MARIE
Last Name:FORTIN
Suffix:
Gender:F
Credentials:LPTA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 GARWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-4127
Mailing Address - Country:US
Mailing Address - Phone:757-318-9088
Mailing Address - Fax:
Practice Address - Street 1:5345 MARIAN LN
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-1841
Practice Address - Country:US
Practice Address - Phone:757-473-0693
Practice Address - Fax:757-473-0694
Is Sole Proprietor?:No
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306602042225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant