Healthcare Provider Details

I. General information

NPI: 1750747572
Provider Name (Legal Business Name): TINNECA FORTIN L.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2016
Last Update Date: 01/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14610 154TH ST E
ORTING WA
98360
US

IV. Provider business mailing address

PO BOX 38
SUMNER WA
98390
US

V. Phone/Fax

Practice location:
  • Phone: 206-708-0616
  • Fax:
Mailing address:
  • Phone: 206-708-0616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberMW60621168
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: