Provider Demographics
NPI:1306963723
Name:FORTIER, KRISTIN DAWN (FNP-C)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:DAWN
Last Name:FORTIER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 HALE
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301
Mailing Address - Country:US
Mailing Address - Phone:985-859-8954
Mailing Address - Fax:
Practice Address - Street 1:22080 HWY 20
Practice Address - Street 2:
Practice Address - City:VACHERIE
Practice Address - State:LA
Practice Address - Zip Code:70090
Practice Address - Country:US
Practice Address - Phone:985-265-3061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP05988363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2119761Medicaid
LA3C865CS40OtherMEDICARE