Provider Demographics
NPI:1982169686
Name:FORTNER, DANIELLE (DC)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:FORTNER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6044 30TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-3334
Mailing Address - Country:US
Mailing Address - Phone:813-360-6820
Mailing Address - Fax:
Practice Address - Street 1:6044 30TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-3334
Practice Address - Country:US
Practice Address - Phone:813-360-6820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12724111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor