Healthcare Provider Details

I. General information

NPI: 1225656424
Provider Name (Legal Business Name): KATELYN FORTENBERY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 LANGDON ST
SOMERSET KY
42503-2750
US

IV. Provider business mailing address

7419 FALLS RIDGE CT
LOUISVILLE KY
40241-6401
US

V. Phone/Fax

Practice location:
  • Phone: 606-679-7441
  • Fax:
Mailing address:
  • Phone: 502-777-7207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: