Provider Demographics
NPI:1245676964
Name:FORTINE, COLLEEN ELIZABETH (LPN)
Entity type:Individual
Prefix:MISS
First Name:COLLEEN
Middle Name:ELIZABETH
Last Name:FORTINE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 VANS TER
Mailing Address - Street 2:
Mailing Address - City:LAKE KATRINE
Mailing Address - State:NY
Mailing Address - Zip Code:12449-5204
Mailing Address - Country:US
Mailing Address - Phone:845-901-1542
Mailing Address - Fax:
Practice Address - Street 1:8 VANS TER
Practice Address - Street 2:
Practice Address - City:LAKE KATRINE
Practice Address - State:NY
Practice Address - Zip Code:12449-5204
Practice Address - Country:US
Practice Address - Phone:845-901-1542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311536-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse