MEDICARE: NEDRA S FORTSON AGPCNP-BC, RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN131505	GA
2	363LA2200X	Adult Health Nurse Practitioner	RN131505	GA
3	363LG0600X	Gerontology Nurse Practitioner	RN131505	GA

General Provider Information

NPI Number	:	1568804987
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NEDRA S FORTSON AGPCNP-BC, RN

Provider Business Mailing Address
First Line	:	PO BOX 71802
Second Line	:
City	:	ALBANY
State	:	GA
Zip	:	31708-1802
Country	:	US
Telephone Number	:	770-330-8496
Fax Number	:	229-435-6173

Provider Business Practice Location Address
First Line	:	802 N JEFFERSON ST
Second Line	:
City	:	ALBANY
State	:	GA
Zip	:	31701-2363
Country	:	US
Telephone Number	:	229-888-7445
Fax Number	:	229-888-7421

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2013
Last Update Date	:	08/19/2014

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