Provider Demographics
NPI:1457066516
Name:FORTNEY, RACHEAL FAWN
Entity Type:Individual
Prefix:
First Name:RACHEAL
Middle Name:FAWN
Last Name:FORTNEY
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 1:100 W MAIN ST FL 4
Mailing Address - Street 2:
Mailing Address - City:PAWHUSKA
Mailing Address - State:OK
Mailing Address - Zip Code:74056-4149
Mailing Address - Country:US
Mailing Address - Phone:918-287-3286
Mailing Address - Fax:
Practice Address - Street 1:100 W MAIN ST FL 4
Practice Address - Street 2:
Practice Address - City:PAWHUSKA
Practice Address - State:OK
Practice Address - Zip Code:74056-4149
Practice Address - Country:US
Practice Address - Phone:918-287-3286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist