Provider Demographics
NPI:1366902066
Name:FORT, MARY KATHRYN (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:FORT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KATHRYN
Other - Last Name:ACKLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1512 W KIRBY PL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3822
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1541 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-626-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP10094363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily