Basic Information
| Provider Information | |||||||||
| NPI: | 1861757122 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORTIN | ||||||||
| FirstName: | AMBER | ||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16 VAUTRIN AVE | ||||||||
| Address2: | |||||||||
| City: | HOLTSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117421624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319606124 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 263 BLUE POINT AVE | ||||||||
| Address2: | |||||||||
| City: | BLUE POINT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117151224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314196737 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2012 | ||||||||
| LastUpdateDate: | 07/11/2012 | ||||||||
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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 | 164W00000X | 305959 | NY | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.