Provider Demographics
NPI:1487122065
Name:FORTNER, TRACEY M (FNP-BC)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:M
Last Name:FORTNER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:M
Other - Last Name:FORTNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:1103 MASON LEE AVE
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-8635
Mailing Address - Country:US
Mailing Address - Phone:678-315-7151
Mailing Address - Fax:
Practice Address - Street 1:1103 MASON LEE AVE
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-8635
Practice Address - Country:US
Practice Address - Phone:678-315-7151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN164997363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA$$$$$$$$$OtherSOCIAL SECURITY
GA$$$$$$$$$Medicaid