Provider Demographics
NPI:1538567854
Name:FORTUNE, GERTRUDE J JENNIE
Entity type:Individual
Prefix:
First Name:GERTRUDE J
Middle Name:JENNIE
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 1:13730 242ND ST
Mailing Address - Street 2:ROSEDALE NY
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-1719
Mailing Address - Country:US
Mailing Address - Phone:917-744-7264
Mailing Address - Fax:
Practice Address - Street 1:13730 242ND ST
Practice Address - Street 2:ROSEDALE NY
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-1719
Practice Address - Country:US
Practice Address - Phone:917-744-7264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY282325-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse