Healthcare Provider Details

I. General information

NPI: 1790179547
Provider Name (Legal Business Name): CRYSTAL FORTIN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2015
Last Update Date: 03/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 E CHESTNUT ST
AUGUSTA ME
04330-5736
US

IV. Provider business mailing address

23 HEMLOCK RIDGE RD
CHELSEA ME
04330-1194
US

V. Phone/Fax

Practice location:
  • Phone: 207-485-7328
  • Fax:
Mailing address:
  • Phone: 207-485-7328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN56346
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: