Provider Demographics
NPI:1144906843
Name:FORTSON, QUANEISHA (FNP-BC)
Entity type:Individual
Prefix:MS
First Name:QUANEISHA
Middle Name:
Last Name:FORTSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 BUTTERFIELD RD.
Mailing Address - Street 2:SUITE 800
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60518
Mailing Address - Country:US
Mailing Address - Phone:615-479-8787
Mailing Address - Fax:
Practice Address - Street 1:1901 BUTTERFIELD RD.
Practice Address - Street 2:SUITE 800
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60518
Practice Address - Country:US
Practice Address - Phone:615-479-8787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.028354363L00000X, 363LF0000X
IL041434656163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse