Provider Demographics
NPI:1053896654
Name:FORTUNE, HERMANCE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:HERMANCE
Middle Name:
Last Name:FORTUNE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1814 SHERMAN SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-3834
Mailing Address - Country:US
Mailing Address - Phone:314-540-8814
Mailing Address - Fax:
Practice Address - Street 1:11133 DUNN RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6163
Practice Address - Country:US
Practice Address - Phone:314-653-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-28
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017891363LF0000X
MO2018015056363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily