Individual
NICHOLE SUSANNA FORTIN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
701 GROVE RD FL 5, GREENVILLE, SC 29605-4210
(864) 455-4411
(864) 455-4480
Mailing address
1 INDEPENDENCE PT, STE 212, GREENVILLE, SC 29615-4545
(864) 797-6306
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
2267
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2063PA
—
SC
Enumeration date
02/16/2011
Last updated
04/24/2015
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