Healthcare Provider Details

I. General information

NPI: 1699074930
Provider Name (Legal Business Name): MARILYN EVELYN FORTIN REG NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2011
Last Update Date: 03/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 CONSTITUTION BLVD BLDG 400 SUITE 202
SALINAS CA
93906-3100
US

IV. Provider business mailing address

1441 CONSTITUTION BLVD BLDG 400 SUITE 202
SALINAS CA
93906-3100
US

V. Phone/Fax

Practice location:
  • Phone: 831-796-1700
  • Fax: 831-769-0552
Mailing address:
  • Phone: 831-796-1700
  • Fax: 831-769-0552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number68971
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: