Provider Demographics
NPI:1679461156
Name:FORTENBERRY, AMARION
Entity type:Individual
Prefix:
First Name:AMARION
Middle Name:
Last Name:FORTENBERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MS
Mailing Address - Zip Code:39429-2059
Mailing Address - Country:US
Mailing Address - Phone:601-731-8446
Mailing Address - Fax:769-213-2422
Practice Address - Street 1:309 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429-2059
Practice Address - Country:US
Practice Address - Phone:601-731-8446
Practice Address - Fax:769-213-2422
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-25
Last Update Date:2025-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS291U00000X, 376J00000X
374U00000X, 385H00000X, 376K00000X, 385HR2060X, 253Z00000X, 172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive Care
No291U00000XLaboratoriesClinical Medical Laboratory
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
No385H00000XRespite Care FacilityRespite Care
No376K00000XNursing Service Related ProvidersNurse's Aide
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No172A00000XOther Service ProvidersDriverGroup - Single Specialty