Provider Demographics
NPI:1326330119
Name:FORTENBERRY-GRATIAS, DENISE FORTENBERRY (ACNP-C)
Entity Type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:FORTENBERRY
Last Name:FORTENBERRY-GRATIAS
Suffix:
Gender:F
Credentials:ACNP-C
Other - Prefix:MS
Other - First Name:DENISE
Other - Middle Name:RENEE
Other - Last Name:FORTENBERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ACNP-C
Mailing Address - Street 1:520 SUPERIOR AVE,
Mailing Address - Street 2:SUITE 350
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663
Mailing Address - Country:US
Mailing Address - Phone:949-764-8062
Mailing Address - Fax:949-764-5607
Practice Address - Street 1:520 SUPERIOR AVE,
Practice Address - Street 2:SUITE 350
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663
Practice Address - Country:US
Practice Address - Phone:949-764-8062
Practice Address - Fax:949-764-5607
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-11
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17284363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care