Basic Information
| Provider Information | |||||||||
| NPI: | 1306190319 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORTNER | ||||||||
| FirstName: | KELLIE | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | A.R.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 HEALTH PARK BLVD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320865784 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 HEALTH PARK BLVD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320865784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048195155 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2012 | ||||||||
| LastUpdateDate: | 06/17/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP9266139 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | P01160791 | 01 | FL | RAILROAD | OTHER | 008049800 | 05 | FL | MEDICAID | Y0F42 | 01 | FL | BCBS | OTHER |