Provider Demographics
NPI:1902226970
Name:FORTINO, FLORENCE
Entity Type:Individual
Prefix:
First Name:FLORENCE
Middle Name:
Last Name:FORTINO
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 1:3103 HULMEVILLE RD.
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BENSALEM
Mailing Address - State:PA
Mailing Address - Zip Code:19020-1705
Mailing Address - Country:US
Mailing Address - Phone:215-708-1645
Mailing Address - Fax:
Practice Address - Street 1:3103 HULMEVILLE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:BENSALEM
Practice Address - State:PA
Practice Address - Zip Code:19020-4381
Practice Address - Country:US
Practice Address - Phone:215-708-1645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-17
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA176137K1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered