Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080A0000X | Adolescent Medicine | 51267 | CT |
NPI | 1184779555 |
---|---|
Provider Name | Rachel Fortune |
First Address | Woodbridge, CT 06525-1126 |
Second Address | Bethlehem, CT 06751-1101 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/01/2007 |
Last Update Date | 11/07/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
49437518 | (05) | CO |