Provider Demographics
NPI:1639983349
Name:FORTNER, TABITHA R (CRANIAL PROSTHESIS)
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:R
Last Name:FORTNER
Suffix:
Gender:F
Credentials:CRANIAL PROSTHESIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 HORSE POINTE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-1225
Mailing Address - Country:US
Mailing Address - Phone:323-921-5084
Mailing Address - Fax:
Practice Address - Street 1:5710 SIMMONS ST # A1
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-9900
Practice Address - Country:US
Practice Address - Phone:323-921-5084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-03
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier