Healthcare Provider Details

I. General information

NPI: 1982057592
Provider Name (Legal Business Name): DEBORAH FORTENBERRY L.H.I.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2016
Last Update Date: 09/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 N STATE ST SUITE 107
JACKSON MS
39202-2407
US

IV. Provider business mailing address

2025 BUENA VISTA DRIVE
VESTAVIA HILLS AL
35216
US

V. Phone/Fax

Practice location:
  • Phone: 601-352-4613
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number45HAO285
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: