Provider Demographics
NPI:1679623896
Name:FORTIN, NANCY J (ANPC)
Entity type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:J
Last Name:FORTIN
Suffix:
Gender:F
Credentials:ANPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:279 BEAVER DRIVE
Mailing Address - Street 2:
Mailing Address - City:MASTIC BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11951
Mailing Address - Country:US
Mailing Address - Phone:631-399-4843
Mailing Address - Fax:631-360-4790
Practice Address - Street 1:75 LANDING MEADOW RD
Practice Address - Street 2:OPTI HEALTH CARE
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787
Practice Address - Country:US
Practice Address - Phone:631-360-4700
Practice Address - Fax:631-360-4790
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYF303613363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P83278Medicare UPIN