Provider Demographics
NPI:1568485266
Name:FORTNER, LEANNE M (MD)
Entity Type:Individual
Prefix:
First Name:LEANNE
Middle Name:M
Last Name:FORTNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6925 E 96TH ST
Mailing Address - Street 2:#150
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-3648
Mailing Address - Country:US
Mailing Address - Phone:317-842-2909
Mailing Address - Fax:317-576-5313
Practice Address - Street 1:6925 E 96TH ST
Practice Address - Street 2:#150
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-3648
Practice Address - Country:US
Practice Address - Phone:317-842-2909
Practice Address - Fax:317-576-5313
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01055016A207Q00000X
IN01055016207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000313038OtherANTHEM
INH87617Medicare UPIN
IN215140BMedicare PIN