MEDICARE: MRS. MARY ELIZABETH FORTMAN N.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	71010812A	IN
2	363L00000X	Nurse Practitioner	71010812A	IN

General Provider Information

NPI Number	:	1942892682
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY ELIZABETH FORTMAN N.P.

Provider Business Mailing Address
First Line	:	1828 S. TYLAND BLVD.
Second Line	:
City	:	NEW HAVEN
State	:	IN
Zip	:	46774
Country	:	US
Telephone Number	:	260-615-1031
Fax Number	:

Provider Business Practice Location Address
First Line	:	PARKVIEW HEALTH
Second Line	:	11108 PARKVIEW CIRCLE DR, DOOR 10
City	:	FT. WAYNE
State	:	IN
Zip	:	46845
Country	:	US
Telephone Number	:	260-266-1000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/04/2021
Last Update Date	:	02/04/2021

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