Provider Demographics
NPI:1740573047
Name:FORTENBERRY, LINDSEY MARLOWE (NP)
Entity Type:Individual
Prefix:
First Name:LINDSEY
Middle Name:MARLOWE
Last Name:FORTENBERRY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CHINABERRY DR STE 1002
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2463
Mailing Address - Country:US
Mailing Address - Phone:318-562-3911
Mailing Address - Fax:318-562-3921
Practice Address - Street 1:1000 CHINABERRY DR STE 1002
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2463
Practice Address - Country:US
Practice Address - Phone:318-562-3911
Practice Address - Fax:318-562-3921
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06299363LW0102X, 363LX0001X, 363LF0000X
TX121136363LF0000X
TXAP121136363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2534530Medicaid