Provider Demographics
NPI:1730586991
Name:FORTUNE, AMANDA (CNM)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:FORTUNE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 DUVAL AVE
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70364-3102
Mailing Address - Country:US
Mailing Address - Phone:504-201-1900
Mailing Address - Fax:
Practice Address - Street 1:530 DUVAL AVE
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70364-3102
Practice Address - Country:US
Practice Address - Phone:504-201-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-03
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08064207VX0000X
LARN126526163WW0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CNM2337OtherAMCB
MS00338278Medicaid
LARN126526OtherLSBN
LAAP08064OtherLSBN
LA2382063Medicaid
LARN126526OtherLSBN