Healthcare Provider Details

I. General information

NPI: 1598411035
Provider Name (Legal Business Name): MIRANDA J FORTNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2022
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 MOUNTAIN PARK DR
FAIRMONT WV
26554-8992
US

IV. Provider business mailing address

16 MOUNTAIN PARK DR
FAIRMONT WV
26554-8992
US

V. Phone/Fax

Practice location:
  • Phone: 304-816-3687
  • Fax: 304-816-3737
Mailing address:
  • Phone: 304-816-3687
  • Fax: 304-816-3737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License NumberF099263
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: