Provider Demographics
NPI:1003042888
Name:FORTNEY, ASHLEY AYN (OD)
Entity Type:Individual
Prefix:DR
First Name:ASHLEY
Middle Name:AYN
Last Name:FORTNEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1730
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-0030
Mailing Address - Country:US
Mailing Address - Phone:901-409-2901
Mailing Address - Fax:
Practice Address - Street 1:3886 GA HIGHWAY 17 RD
Practice Address - Street 2:
Practice Address - City:EASTANOLLEE
Practice Address - State:GA
Practice Address - Zip Code:30538-3808
Practice Address - Country:US
Practice Address - Phone:706-297-7292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-06
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2465152W00000X
TN2810152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist