Basic Information
| Provider Information | |||||||||
| NPI: | 1407876279 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORTI-GALLANT | ||||||||
| FirstName: | KATHLEEN | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43 WHITING HILL RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | BREWER | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044121006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079735035 | ||||||||
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| Practice Location | |||||||||
| Address1: | 925 UNION ST STE 3 | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044013051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079739980 | ||||||||
| FaxNumber: | 2079737515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 04/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SM0705X | CNP81358 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Medical-Surgical | 364SM0705X | R028705 | ME | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Medical-Surgical |
No ID Information.