Provider Demographics
NPI:1487853990
Name:FORTENBERRY, MELANIE STOVALL (FNP)
Entity Type:Individual
Prefix:MS
First Name:MELANIE
Middle Name:STOVALL
Last Name:FORTENBERRY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:
Other - Last Name:DRAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 653
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32170-0653
Mailing Address - Country:US
Mailing Address - Phone:706-973-0796
Mailing Address - Fax:
Practice Address - Street 1:200 S PARK RD STE 200
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-8541
Practice Address - Country:US
Practice Address - Phone:866-986-2263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9595541163W00000X
GARN164301363LF0000X
FLAPRN11018986363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse