Provider Demographics
NPI:1841951928
Name:FORTNER, COURTNEY (FNP)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:FORTNER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:MARKS
Mailing Address - State:MS
Mailing Address - Zip Code:38646-1832
Mailing Address - Country:US
Mailing Address - Phone:662-326-3502
Mailing Address - Fax:
Practice Address - Street 1:1024 M.L.K. JR. DR.
Practice Address - Street 2:
Practice Address - City:MARKS
Practice Address - State:MS
Practice Address - Zip Code:38646
Practice Address - Country:US
Practice Address - Phone:662-326-3502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-31
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904455163W00000X
MS905127363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse