Provider Demographics
NPI:1629791512
Name:FORTES, NICOLE SCHULTZ (SRNA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SCHULTZ
Last Name:FORTES
Suffix:
Gender:F
Credentials:SRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2164 13TH ST
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18020-4399
Mailing Address - Country:US
Mailing Address - Phone:570-640-8441
Mailing Address - Fax:
Practice Address - Street 1:2164 13TH ST
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18020-4399
Practice Address - Country:US
Practice Address - Phone:570-640-8441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN679762390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program