Provider Demographics
NPI:1407876279
Name:FORTI-GALLANT, KATHLEEN (FNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:FORTI-GALLANT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 WHITING HILL RD STE 300
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-1006
Mailing Address - Country:US
Mailing Address - Phone:207-973-5035
Mailing Address - Fax:
Practice Address - Street 1:925 UNION ST STE 3
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3051
Practice Address - Country:US
Practice Address - Phone:207-973-9980
Practice Address - Fax:207-973-7515
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP81358364SM0705X
MER028705364SM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MENF1640Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER