Provider Demographics
NPI:1174068704
Name:MASON, FORTENISE A (CNP)
Entity type:Individual
Prefix:MRS
First Name:FORTENISE
Middle Name:A
Last Name:MASON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:FORTENISE
Other - Middle Name:A
Other - Last Name:GARRETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:815 EAGLES NEST DR
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272-9328
Mailing Address - Country:US
Mailing Address - Phone:601-421-7235
Mailing Address - Fax:
Practice Address - Street 1:514H E WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4538
Practice Address - Country:US
Practice Address - Phone:601-713-3900
Practice Address - Fax:601-713-3970
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-06
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901481363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily