Provider Demographics
NPI:1346682986
Name:FORTENBERRY, YOLANDA (LPN)
Entity Type:Individual
Prefix:
First Name:YOLANDA
Middle Name:
Last Name:FORTENBERRY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 BRANDON BAY LOOP
Mailing Address - Street 2:
Mailing Address - City:TYLERTOWN
Mailing Address - State:MS
Mailing Address - Zip Code:39667-7169
Mailing Address - Country:US
Mailing Address - Phone:601-551-9883
Mailing Address - Fax:
Practice Address - Street 1:58 BRANDON BAY LOOP
Practice Address - Street 2:
Practice Address - City:TYLERTOWN
Practice Address - State:MS
Practice Address - Zip Code:39667-7169
Practice Address - Country:US
Practice Address - Phone:601-551-9883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-24
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP326055164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse