Provider Demographics
NPI:1700231206
Name:FORTE, DEMETRIUS LAVAL SR (LPN)
Entity Type:Individual
Prefix:MR
First Name:DEMETRIUS
Middle Name:LAVAL
Last Name:FORTE
Suffix:SR
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9040 JACKSON AVENUE, ATTN MCHJ-CLQ-C
Mailing Address - Street 2:MADIGAN ARMY MEDICAL CENTER
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-1000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:253-967-2639
Practice Address - Street 1:9040 JACKSON AVENUE, ATTN MCHJ-CLQ-C
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-1000
Practice Address - Country:US
Practice Address - Phone:253-968-1110
Practice Address - Fax:253-967-2639
Is Sole Proprietor?:No
Enumeration Date:2016-05-03
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00055722164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse