Healthcare Provider Details

I. General information

NPI: 1104744721
Provider Name (Legal Business Name): NICOLE FORTNER-RODRIGUEZ
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9981 S HEALTHPARK DR STE 454
FORT MYERS FL
33908-3618
US

IV. Provider business mailing address

2207 SUNRISE BLVD
FORT MYERS FL
33907-4166
US

V. Phone/Fax

Practice location:
  • Phone: 239-468-8033
  • Fax: 239-468-7953
Mailing address:
  • Phone: 239-322-8499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS69093
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: