MEDICARE: KRISTINA LEIGH FORTIER LAT, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	1346	CT

General Provider Information

NPI Number	:	1891473187
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTINA LEIGH FORTIER LAT, ATC

Provider Business Mailing Address
First Line	:	442 FARMINGTON AVE
Second Line	:
City	:	WATERBURY
State	:	CT
Zip	:	06710-1228
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	700 PROSPECT ST
Second Line	:
City	:	NEW HAVEN
State	:	CT
Zip	:	06511-1224
Country	:	US
Telephone Number	:	203-773-4472
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2023
Last Update Date	:	07/07/2023

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