Healthcare Provider Details

I. General information

NPI: 1407876279
Provider Name (Legal Business Name): KATHLEEN FORTI-GALLANT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 04/06/2020
Certification Date: 04/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 UNION ST STE 3
BANGOR ME
04401-3051
US

IV. Provider business mailing address

43 WHITING HILL RD STE 300
BREWER ME
04412-1006
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-9980
  • Fax: 207-973-7515
Mailing address:
  • Phone: 207-973-5035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SM0705X
TaxonomyMedical-Surgical Clinical Nurse Specialist
License NumberCNP81358
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code364SM0705X
TaxonomyMedical-Surgical Clinical Nurse Specialist
License NumberR028705
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: