Provider Demographics
NPI:1942892682
Name:FORTMAN, MARY ELIZABETH (NP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:FORTMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:WATERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1828 S. TYLAND BLVD.
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:IN
Mailing Address - Zip Code:46774
Mailing Address - Country:US
Mailing Address - Phone:260-615-1031
Mailing Address - Fax:
Practice Address - Street 1:PARKVIEW HEALTH
Practice Address - Street 2:11108 PARKVIEW CIRCLE DR, DOOR 10
Practice Address - City:FT. WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845
Practice Address - Country:US
Practice Address - Phone:260-266-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71010812A363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily