Provider Demographics
NPI:1295923738
Name:FORTILLUS, MARIE-MICHELE (NP)
Entity type:Individual
Prefix:
First Name:MARIE-MICHELE
Middle Name:
Last Name:FORTILLUS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARIE-MICHELE
Other - Middle Name:
Other - Last Name:RHO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2201 HEMPSTEAD TPKE
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-1859
Mailing Address - Country:US
Mailing Address - Phone:516-572-6131
Mailing Address - Fax:516-572-5793
Practice Address - Street 1:2201 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-1859
Practice Address - Country:US
Practice Address - Phone:516-572-6131
Practice Address - Fax:516-572-5793
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY502964163W00000X
NYF390054363LP1700X
NYF420771363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LP1700XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPerinatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF420771OtherWOMEN'S HEALTH NP LICENSE