Provider Demographics
NPI:1053135830
Name:FORTUNA, KELLY (RN, APRN, AGNP-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FORTUNA
Suffix:
Gender:F
Credentials:RN, APRN, AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1295 RANCHLAND DR
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-1558
Mailing Address - Country:US
Mailing Address - Phone:216-386-0106
Mailing Address - Fax:
Practice Address - Street 1:1295 RANCHLAND DR
Practice Address - Street 2:
Practice Address - City:MAYFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44124-1558
Practice Address - Country:US
Practice Address - Phone:216-386-0106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-08
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0038044363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care