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General NPI Number Information
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NPI Number | 1053896654
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Entity Type | Individual
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Provider Name | HERMANCE FORTUNE NURSE PRACTITIONER
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Gender | Female
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Dates
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Enumeration Date | 09/28/2018
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Last Update Date | 11/29/2018
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Provider Practice Location Address
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Address Line | 11133 DUNN RD
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City | SAINT LOUIS
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State | MO
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Zip | 63136-6163
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Country | US
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Telephone | 314-653-5000
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Fax |
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Provider Business Mailing Address
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Address Line | 1814 SHERMAN SQUARE DR
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City | SAINT CHARLES
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State | MO
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Zip | 63303-3834
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Country | US
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Telephone | 314-540-8814
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 209017891
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 2018015056
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License Number State | MO
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Taxonomy #3
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 2018015056
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License Number State | MO
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