Provider Demographics
NPI:1023009495
Name:FORTINI, KATHLEEN E (PNP)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:E
Last Name:FORTINI
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 MILL ST
Mailing Address - Street 2:BUILDING E #17
Mailing Address - City:HANOVER
Mailing Address - State:MA
Mailing Address - Zip Code:02339-1641
Mailing Address - Country:US
Mailing Address - Phone:781-826-2131
Mailing Address - Fax:781-826-4513
Practice Address - Street 1:51 MILL ST
Practice Address - Street 2:BUILDING E #17
Practice Address - City:HANOVER
Practice Address - State:MA
Practice Address - Zip Code:02339-1641
Practice Address - Country:US
Practice Address - Phone:781-826-2131
Practice Address - Fax:781-826-4513
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA154202363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP2408OtherBCBS
MA0390330Medicaid
MA0390330Medicaid
MANP4551Medicare ID - Type Unspecified
MANP2408OtherBCBS