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General NPI Number Information
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NPI Number | 1174068704
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Entity Type | Individual
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Provider Name | FORTENISE A MASON CNP
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Gender | Female
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Dates
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Enumeration Date | 01/06/2017
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Last Update Date | 10/22/2019
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Provider Practice Location Address
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Address Line | 514H E WOODROW WILSON AVE
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City | JACKSON
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State | MS
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Zip | 39216-4538
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Country | US
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Telephone | 601-713-3900
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Fax | 601-713-3970
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Provider Business Mailing Address
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Address Line | 815 EAGLES NEST DR
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City | BYRAM
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State | MS
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Zip | 39272-9328
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Country | US
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Telephone | 601-421-7235
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 901481
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License Number State | MS
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