Healthcare Provider Details

I. General information

NPI: 1215290911
Provider Name (Legal Business Name): JULIE LYNN FORTNER MSED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 CHESTNUT ST
FREDONIA NY
14063-1630
US

IV. Provider business mailing address

83 PULLMAN ST
BROCTON NY
14716-9650
US

V. Phone/Fax

Practice location:
  • Phone: 716-672-2738
  • Fax:
Mailing address:
  • Phone: 716-680-0359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: