Provider Demographics
NPI:1760243737
Name:FORTENBERRY, HANNAH (CRNA)
Entity Type:Individual
Prefix:
First Name:HANNAH
Middle Name:
Last Name:FORTENBERRY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 TERRAPIN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-2244
Mailing Address - Country:US
Mailing Address - Phone:601-955-0763
Mailing Address - Fax:
Practice Address - Street 1:1030 RIVER OAKS DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9553
Practice Address - Country:US
Practice Address - Phone:601-932-1030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901884367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty