Provider Demographics
NPI:1700306487
Name:FORTIN, LEXI ANNE (PTA)
Entity type:Individual
Prefix:
First Name:LEXI
Middle Name:ANNE
Last Name:FORTIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 COMMONS CIR APT 1
Mailing Address - Street 2:
Mailing Address - City:PLOVER
Mailing Address - State:WI
Mailing Address - Zip Code:54467-4225
Mailing Address - Country:US
Mailing Address - Phone:231-631-5215
Mailing Address - Fax:
Practice Address - Street 1:825 WHITING AVE
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-5246
Practice Address - Country:US
Practice Address - Phone:715-346-1374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2017-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2651-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant