Provider Demographics
NPI:1275947608
Name:FORTINA, CHAELI A (APRN)
Entity Type:Individual
Prefix:
First Name:CHAELI
Middle Name:A
Last Name:FORTINA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:988102 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-8102
Mailing Address - Country:US
Mailing Address - Phone:402-559-6195
Mailing Address - Fax:
Practice Address - Street 1:EMILE 42ND ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-1045
Practice Address - Country:US
Practice Address - Phone:402-559-4988
Practice Address - Fax:402-559-9643
Is Sole Proprietor?:No
Enumeration Date:2014-06-13
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE111706363L00000X
IAH137205363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner