Provider Demographics
NPI:1538311048
Name:FORTNEY, RITA ANN (RDH, RN)
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:ANN
Last Name:FORTNEY
Suffix:
Gender:F
Credentials:RDH, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50426 JOHNSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:SOLDIERS GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:54655-7549
Mailing Address - Country:US
Mailing Address - Phone:608-735-4080
Mailing Address - Fax:
Practice Address - Street 1:50426 JOHNSTOWN RD
Practice Address - Street 2:
Practice Address - City:SOLDIERS GROVE
Practice Address - State:WI
Practice Address - Zip Code:54655-7549
Practice Address - Country:US
Practice Address - Phone:608-735-4080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-15
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4521-016124Q00000X
WI139651-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
No163W00000XNursing Service ProvidersRegistered Nurse