Healthcare Provider Details

I. General information

NPI: 1295923738
Provider Name (Legal Business Name): MARIE-MICHELE FORTILLUS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARIE-MICHELE RHO

II. Dates (important events)

Enumeration Date: 10/10/2007
Last Update Date: 10/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 HEMPSTEAD TPKE
EAST MEADOW NY
11554-1859
US

IV. Provider business mailing address

2201 HEMPSTEAD TPKE
EAST MEADOW NY
11554-1859
US

V. Phone/Fax

Practice location:
  • Phone: 516-572-6131
  • Fax: 516-572-5793
Mailing address:
  • Phone: 516-572-6131
  • Fax: 516-572-5793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number502964
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LP1700X
TaxonomyPerinatal Nurse Practitioner
License NumberF390054
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberF420771
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: