1942344908 NPI number — TERESA M. FORTNER M.O.T. OTR L

Table of content: TERESA M. FORTNER M.O.T. OTR L (NPI 1942344908)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942344908 NPI number — TERESA M. FORTNER M.O.T. OTR L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORTNER
Provider First Name:
TERESA
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.O.T. OTR L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942344908
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3512 FOY GLEN CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APEX
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27539-3682
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-815-0638
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3716 NATIONAL DR
Provider Second Line Business Practice Location Address:
SUITE 124
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27612-4068
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-815-0638
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  4712 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com