Provider Demographics
NPI:1194727735
Name:FORTENBERRY, LORA J (NP)
Entity type:Individual
Prefix:
First Name:LORA
Middle Name:J
Last Name:FORTENBERRY
Suffix:
Gender:F
Credentials:NP
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 4237
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46082-4237
Mailing Address - Country:US
Mailing Address - Phone:317-218-2800
Mailing Address - Fax:317-818-8921
Practice Address - Street 1:8925 N MERIDIAN ST
Practice Address - Street 2:150
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2386
Practice Address - Country:US
Practice Address - Phone:317-846-1846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000856A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
203960BMedicare ID - Type Unspecified
P80551Medicare UPIN