Provider Demographics
NPI:1407044027
Name:FORTIER, KIMBERLY E (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:E
Last Name:FORTIER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17567
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32522-7567
Mailing Address - Country:US
Mailing Address - Phone:850-437-8810
Mailing Address - Fax:
Practice Address - Street 1:1717 N E ST STE 205
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-6336
Practice Address - Country:US
Practice Address - Phone:850-437-8810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110538363A00000X
FL9110538363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022043800Medicaid
MS393384YNE2Medicare PIN