Healthcare Provider Details

I. General information

NPI: 1760243737
Provider Name (Legal Business Name): HANNAH FORTENBERRY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2024
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 RIVER OAKS DR
FLOWOOD MS
39232-9553
US

IV. Provider business mailing address

233 TERRAPIN CREEK RD
BRANDON MS
39042-2244
US

V. Phone/Fax

Practice location:
  • Phone: 601-932-1030
  • Fax:
Mailing address:
  • Phone: 601-955-0763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number901884
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: