Healthcare Provider Details

I. General information

NPI: 1487018784
Provider Name (Legal Business Name): KRISTEN FORTIN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 12/10/2020
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3393 G ST STE C
MERCED CA
95340-1001
US

IV. Provider business mailing address

PO BOX 3768
MERCED CA
95344-3768
US

V. Phone/Fax

Practice location:
  • Phone: 209-580-4172
  • Fax: 209-233-9859
Mailing address:
  • Phone: 209-725-7149
  • Fax: 209-726-0134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95004063
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: