Provider Demographics
NPI:1578974135
Name:FORTALEZA, PABLO SIMEON LIMON
Entity Type:Individual
Prefix:MR
First Name:PABLO SIMEON
Middle Name:LIMON
Last Name:FORTALEZA
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 1:7 SOUTHWOOD LN
Mailing Address - Street 2:
Mailing Address - City:NORTH BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11703-3608
Mailing Address - Country:US
Mailing Address - Phone:631-661-2056
Mailing Address - Fax:
Practice Address - Street 1:7 SOUTHWOOD LN
Practice Address - Street 2:
Practice Address - City:NORTH BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11703-3608
Practice Address - Country:US
Practice Address - Phone:631-661-2056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY665305-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse