| Doctor Name: | NICOLE FORTLAGE |
| NPI Number: | 1063758217 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | MSN RN PMHNP |
| License Number: | RN275578 |
| Business Practice Address: | 520 N Chestnut St Ravenna, OH - 442662218 |
| Business Phone Number: | 3302965552 |
| Business Fax Number: | |
| Mailing Address: | 520 N Chestnut St, RAVENNA |
| State: | OH |
| Postal Code: | 442662218 |
| Phone Number: | 3302965552 |
| Fax Number: | |
| NPI Enumeration Date: | 12/17/2012 |
| NPI Last Update Date: | 09/26/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 163WP0808X |
| License Number: | RN275578 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | OH |
| Taxonomy Type: | Nursing Service Providers |
| Taxonomy Classification: | Registered Nurse |
| Taxonomy Specialization: | Psych/Mental Health |
| Taxonomy Definition: | |