Provider Demographics
NPI:1609228352
Name:FORTENBERRY, EBONE MONIQUE
Entity Type:Individual
Prefix:MRS
First Name:EBONE
Middle Name:MONIQUE
Last Name:FORTENBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 WALENDA DR NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-9730
Mailing Address - Country:US
Mailing Address - Phone:706-314-9294
Mailing Address - Fax:706-314-9295
Practice Address - Street 1:169 WALENDA DR NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-9730
Practice Address - Country:US
Practice Address - Phone:706-314-9294
Practice Address - Fax:706-314-9295
Is Sole Proprietor?:No
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker