Provider Demographics
NPI:1013514702
Name:FORTNER, LEEZA
Entity Type:Individual
Prefix:
First Name:LEEZA
Middle Name:
Last Name:FORTNER
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 1:33708 LIPKE ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-3618
Mailing Address - Country:US
Mailing Address - Phone:586-846-1282
Mailing Address - Fax:
Practice Address - Street 1:259 MACK AVE STE 4514
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2427
Practice Address - Country:US
Practice Address - Phone:313-577-4723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program