Provider Demographics
NPI:1073668067
Name:FORTUNE, ROBIN DALE
Entity Type:Individual
Prefix:MR
First Name:ROBIN
Middle Name:DALE
Last Name:FORTUNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5099 SPORTSMAN LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-8216
Mailing Address - Country:US
Mailing Address - Phone:270-369-8984
Mailing Address - Fax:270-369-8562
Practice Address - Street 1:5099 SPORTSMAN LAKE RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-8216
Practice Address - Country:US
Practice Address - Phone:270-369-8984
Practice Address - Fax:270-369-8562
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYSA050246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYSA050OtherKBML CERTIFICATION NO.