Provider Demographics
NPI:1124636782
Name:FORTENBERRY, MELISSA LYNN
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:LYNN
Last Name:FORTENBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 WALLACE ST
Mailing Address - Street 2:
Mailing Address - City:MENDENHALL
Mailing Address - State:MS
Mailing Address - Zip Code:39114-3807
Mailing Address - Country:US
Mailing Address - Phone:769-229-1940
Mailing Address - Fax:
Practice Address - Street 1:507 WALLACE ST
Practice Address - Street 2:
Practice Address - City:MENDENHALL
Practice Address - State:MS
Practice Address - Zip Code:39114-3807
Practice Address - Country:US
Practice Address - Phone:769-229-1940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-20
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No385H00000XRespite Care FacilityRespite Care