Healthcare Provider Details

I. General information

NPI: 1972151769
Provider Name (Legal Business Name): ADRIENNE GRAEUB FORTNER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ADRIENNE GRAEUB APRN

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

638 E COLLEGE AVE STE B
STANTON KY
40380-2363
US

IV. Provider business mailing address

638 E COLLEGE AVE STE B
STANTON KY
40380-2363
US

V. Phone/Fax

Practice location:
  • Phone: 606-318-3500
  • Fax: 606-318-3503
Mailing address:
  • Phone: 606-318-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3013555
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: