Provider Demographics
NPI:1669796652
Name:FORTNER, TERRI DAWN (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:TERRI
Middle Name:DAWN
Last Name:FORTNER
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-5638
Mailing Address - Country:US
Mailing Address - Phone:505-325-0238
Mailing Address - Fax:505-327-7247
Practice Address - Street 1:1001 W. BROADWAY
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-325-0238
Practice Address - Fax:505-327-7247
Is Sole Proprietor?:No
Enumeration Date:2010-03-18
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP01563363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health