Healthcare Provider Details

I. General information

NPI: 1861494064
Provider Name (Legal Business Name): CYNTHIA L FORT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 10/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 MEDICAL VILLAGE DR
NEWPORT VT
05855-9834
US

IV. Provider business mailing address

121 MEDICAL VILLAGE DR
NEWPORT VT
05855-9834
US

V. Phone/Fax

Practice location:
  • Phone: 802-334-5929
  • Fax: 802-487-1051
Mailing address:
  • Phone:
  • Fax: 802-487-1051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1010022369
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: