Healthcare Provider Details

I. General information

NPI: 1306190319
Provider Name (Legal Business Name): KELLIE JEAN FORTNER A.R.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2012
Last Update Date: 06/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 HEALTH PARK BLVD STE 300
ST AUGUSTINE FL
32086-5784
US

IV. Provider business mailing address

400 HEALTH PARK BLVD STE 300
ST AUGUSTINE FL
32086-5784
US

V. Phone/Fax

Practice location:
  • Phone: 904-819-5155
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9266139
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: