Provider Demographics
NPI:1245650530
Name:FORTNER, BEVERLY COCO (AP)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:COCO
Last Name:FORTNER
Suffix:
Gender:F
Credentials:AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 NE 50TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33137-2713
Mailing Address - Country:US
Mailing Address - Phone:786-660-3389
Mailing Address - Fax:
Practice Address - Street 1:1450 MADRUGA AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-3148
Practice Address - Country:US
Practice Address - Phone:305-667-3910
Practice Address - Fax:305-667-3915
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP2985171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist