Provider Demographics
NPI:1750345005
Name:FORTENBERRY, KIMBERLY PHILLIPS
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:PHILLIPS
Last Name:FORTENBERRY
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 1:120 INNWOOD DR
Mailing Address - Street 2:COVINGTON
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-9123
Mailing Address - Country:US
Mailing Address - Phone:985-892-3225
Mailing Address - Fax:985-234-0628
Practice Address - Street 1:1202 S TYLER ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-2330
Practice Address - Country:US
Practice Address - Phone:985-898-4000
Practice Address - Fax:985-898-4394
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901488367500000X
LARN072659367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1569755Medicaid
430057274OtherRR MEDICARE NUMBER
LA1569755Medicaid