Healthcare Provider Details

I. General information

NPI: 1235045865
Provider Name (Legal Business Name): COLTON L FORTNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2026
Last Update Date: 08/22/2026
Certification Date: 08/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1907 W SYCAMORE ST
KOKOMO IN
46901-5148
US

IV. Provider business mailing address

1907 W SYCAMORE ST
KOKOMO IN
46901-5148
US

V. Phone/Fax

Practice location:
  • Phone: 765-456-5560
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number7698-9090
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: