Provider Demographics
NPI:1053552158
Name:FORTNER, KELLY SUSAN (DPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:SUSAN
Last Name:FORTNER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:SUSAN
Other - Last Name:DICKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:659 S SALISBURY BLVD
Mailing Address - Street 2:STE 1B
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-5458
Mailing Address - Country:US
Mailing Address - Phone:410-831-3226
Mailing Address - Fax:410-677-0883
Practice Address - Street 1:2895 HAMILTON BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-6172
Practice Address - Country:US
Practice Address - Phone:610-841-3555
Practice Address - Fax:610-841-3558
Is Sole Proprietor?:No
Enumeration Date:2009-03-19
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT019678225100000X
NJ40QA01309100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ175262V2CMedicare PIN
PA161874VNAMedicare PIN