Provider Demographics
NPI:1487206975
Name:FORTNEY, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:FORTNEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9516 DAYTON PIKE APT 216
Mailing Address - Street 2:
Mailing Address - City:SODDY DAISY
Mailing Address - State:TN
Mailing Address - Zip Code:37379-4760
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:437 ALEXIAN WAY
Practice Address - Street 2:
Practice Address - City:SIGNAL MOUNTAIN
Practice Address - State:TN
Practice Address - Zip Code:37377-1954
Practice Address - Country:US
Practice Address - Phone:423-886-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
TN5573235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist