Provider Demographics
NPI:1881176782
Name:FORTNEY, MICHELLE (REGISTERED NURSE)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:
Last Name:FORTNEY
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 KINGS RD
Mailing Address - Street 2:
Mailing Address - City:WEST COXSACKIE
Mailing Address - State:NY
Mailing Address - Zip Code:12192-2904
Mailing Address - Country:US
Mailing Address - Phone:518-756-3351
Mailing Address - Fax:
Practice Address - Street 1:204 KINGS RD
Practice Address - Street 2:
Practice Address - City:WEST COXSACKIE
Practice Address - State:NY
Practice Address - Zip Code:12192-2904
Practice Address - Country:US
Practice Address - Phone:518-756-3351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY407509163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice