Healthcare Provider Details

I. General information

NPI: 1841951928
Provider Name (Legal Business Name): COURTNEY FORTNER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/31/2021
Last Update Date: 05/26/2022
Certification Date: 04/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 M.L.K. JR. DR.
MARKS MS
38646
US

IV. Provider business mailing address

1024 MARTIN LUTHER KING DR
MARKS MS
38646-1832
US

V. Phone/Fax

Practice location:
  • Phone: 662-326-3502
  • Fax:
Mailing address:
  • Phone: 662-326-3502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number904455
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number905127
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: