Healthcare Provider Details

I. General information

NPI: 1154950905
Provider Name (Legal Business Name): MACY ELIZABETH FORTNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2020
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 HEMLOCK SHOALS DR
DAWSONVILLE GA
30534-0043
US

IV. Provider business mailing address

25 HEMLOCK SHOALS DR
DAWSONVILLE GA
30534-0043
US

V. Phone/Fax

Practice location:
  • Phone: 770-533-3398
  • Fax:
Mailing address:
  • Phone: 770-533-3398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN277679
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN277679
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: