Provider Demographics
NPI:1568804987
Name:FORTSON, NEDRA S (AGPCNP-BC, RN)
Entity Type:Individual
Prefix:
First Name:NEDRA
Middle Name:S
Last Name:FORTSON
Suffix:
Gender:F
Credentials:AGPCNP-BC, RN
Other - Prefix:
Other - First Name:NEDRA
Other - Middle Name:LACHELLE
Other - Last Name:SPEIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 71802
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31708-1802
Mailing Address - Country:US
Mailing Address - Phone:770-330-8496
Mailing Address - Fax:229-435-6173
Practice Address - Street 1:802 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-2363
Practice Address - Country:US
Practice Address - Phone:229-888-7445
Practice Address - Fax:229-888-7421
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-26
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN131505163W00000X, 363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology