Healthcare Provider Details

I. General information

NPI: 1336652528
Provider Name (Legal Business Name): REBECCA LYNNE FORTIER RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2017
Last Update Date: 11/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 WOODLAND ST
HARTFORD CT
06105-2363
US

IV. Provider business mailing address

76 WATER ST
SOUTH GLASTONBURY CT
06073-2226
US

V. Phone/Fax

Practice location:
  • Phone: 860-793-3500
  • Fax:
Mailing address:
  • Phone: 508-617-3806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN2294707
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: