Provider Demographics
NPI:1003117532
Name:FORT, SUSAN LYNETTE (ARNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNETTE
Last Name:FORT
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2528 NW 32ND ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-2743
Mailing Address - Country:US
Mailing Address - Phone:352-224-8161
Mailing Address - Fax:321-321-8780
Practice Address - Street 1:2528 NW 32ND ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-2743
Practice Address - Country:US
Practice Address - Phone:352-224-8161
Practice Address - Fax:321-320-8780
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-15
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 3295302363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health