Provider Demographics
NPI:1770606758
Name:FORTUNA, MOLLY
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:FORTUNA
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 1:710 NIGHTHAWK CIR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-3132
Mailing Address - Country:US
Mailing Address - Phone:303-604-6881
Mailing Address - Fax:
Practice Address - Street 1:119 UCB
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80309-0119
Practice Address - Country:US
Practice Address - Phone:303-492-2030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4078101YM0800X
CO54997163WW0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory