Healthcare Provider Details

I. General information

NPI: 1275357121
Provider Name (Legal Business Name): BRENTENEY FORTUNE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2024
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 HOUSTON LAKE RD
FULTON MS
38843-8992
US

IV. Provider business mailing address

101 HOUSTON LAKE RD
FULTON MS
38843-8992
US

V. Phone/Fax

Practice location:
  • Phone: 662-891-1889
  • Fax:
Mailing address:
  • Phone: 662-891-1889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number908070
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: