Provider Demographics
NPI:1174024848
Name:FORTUNE, MARIE LOURDES
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:LOURDES
Last Name:FORTUNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20959 111TH AVE
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429-1727
Mailing Address - Country:US
Mailing Address - Phone:347-455-6505
Mailing Address - Fax:
Practice Address - Street 1:20959 111TH AVE
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11429-1727
Practice Address - Country:US
Practice Address - Phone:347-455-6505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY329024164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse