Provider Demographics
NPI:1275024523
Name:FORT, LATEISHA NICOLE (APN)
Entity Type:Individual
Prefix:MS
First Name:LATEISHA
Middle Name:NICOLE
Last Name:FORT
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-3558
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:
Practice Address - Street 1:3551 HIGHLAND AVE STE 200A
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-2100
Practice Address - Country:US
Practice Address - Phone:844-376-3876
Practice Address - Fax:630-929-0633
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017544363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL921750533OtherPRIMARY CARE