Provider Demographics
NPI:1497129159
Name:FORT, ANNAIL REESE (CERTIFIED HAIR LOSS)
Entity Type:Individual
Prefix:
First Name:ANNAIL
Middle Name:REESE
Last Name:FORT
Suffix:
Gender:F
Credentials:CERTIFIED HAIR LOSS
Other - Prefix:
Other - First Name:ANNAIL
Other - Middle Name:REESE
Other - Last Name:FORT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3009B MCGEHEE RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36111-2202
Mailing Address - Country:US
Mailing Address - Phone:334-280-3930
Mailing Address - Fax:
Practice Address - Street 1:3009B MCGEHEE RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36111-2202
Practice Address - Country:US
Practice Address - Phone:334-280-3930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-18
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL59208174400000X
AL174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
0012375683899003082OtherUNITEDHEALTHCARE