Provider Demographics
NPI:1902643729
Name:FORTMAN, STEPHANIE ANN (PMHNP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:FORTMAN
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 304
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE CITY
Mailing Address - State:IN
Mailing Address - Zip Code:47327-0304
Mailing Address - Country:US
Mailing Address - Phone:765-698-8192
Mailing Address - Fax:
Practice Address - Street 1:1311 W 96TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1191
Practice Address - Country:US
Practice Address - Phone:765-698-8192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-10
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28268154A163W00000X
IN71016070A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse