Provider Demographics
NPI:1609535053
Name:FORTIER, ELIZABETH ANNE
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANNE
Last Name:FORTIER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1972 COUNTY ROAD 1985 N
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62827-2215
Mailing Address - Country:US
Mailing Address - Phone:901-336-9236
Mailing Address - Fax:
Practice Address - Street 1:1972 COUNTY ROAD 1985 N
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62827-2215
Practice Address - Country:US
Practice Address - Phone:901-336-9236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.495246163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health