Provider Demographics
NPI:1164824561
Name:FORTKAMP, MARY (RN RRT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:FORTKAMP
Suffix:
Gender:F
Credentials:RN RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6797 SILVER LAKES DR
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45822-8215
Mailing Address - Country:US
Mailing Address - Phone:419-586-2912
Mailing Address - Fax:937-547-5780
Practice Address - Street 1:6797 SILVER LAKES DR
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822-8215
Practice Address - Country:US
Practice Address - Phone:419-586-2912
Practice Address - Fax:937-547-5780
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH332407163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse