Provider Demographics
NPI:1710206495
Name:FORTNER, LEANN JEANETTE (MA)
Entity Type:Individual
Prefix:
First Name:LEANN
Middle Name:JEANETTE
Last Name:FORTNER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:LEANN
Other - Middle Name:JEANETTE
Other - Last Name:LANDRETH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:4700 WATERS AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6220
Mailing Address - Country:US
Mailing Address - Phone:912-350-3627
Mailing Address - Fax:
Practice Address - Street 1:4700 WATERS AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6220
Practice Address - Country:US
Practice Address - Phone:912-350-3627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-20
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0832235Z00000X
GASLP007832235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003127569BMedicaid