Provider Demographics
NPI:1275024523
Name:FORT, LATEISHA NICOLE (APN-FPA)
Entity type:Individual
Prefix:MS
First Name:LATEISHA
Middle Name:NICOLE
Last Name:FORT
Suffix:
Gender:F
Credentials:APN-FPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18241 WEST ST STE 209
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438-3200
Mailing Address - Country:US
Mailing Address - Phone:800-897-4575
Mailing Address - Fax:800-306-9509
Practice Address - Street 1:1 INGALLS DR
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-3558
Practice Address - Country:US
Practice Address - Phone:708-596-3344
Practice Address - Fax:708-596-3432
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2024-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277002648363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL921750533001Medicaid