Provider Demographics
NPI:1902569163
Name:FORTE, TISA D (RN)
Entity Type:Individual
Prefix:
First Name:TISA
Middle Name:D
Last Name:FORTE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:130 S INDIAN RIVER DR STE 202
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-4353
Mailing Address - Country:US
Mailing Address - Phone:772-360-1503
Mailing Address - Fax:
Practice Address - Street 1:130 S INDIAN RIVER DR STE 202
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4353
Practice Address - Country:US
Practice Address - Phone:772-360-1503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9430659163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse