Provider Demographics
NPI:1477272169
Name:FORTUNE, STEPHON DELOREAN
Entity Type:Individual
Prefix:
First Name:STEPHON
Middle Name:DELOREAN
Last Name:FORTUNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2710 SHERIDAN RD SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-5297
Mailing Address - Country:US
Mailing Address - Phone:202-321-3602
Mailing Address - Fax:
Practice Address - Street 1:2710 SHERIDAN RD SE # 102
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-5297
Practice Address - Country:US
Practice Address - Phone:202-321-3602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant