Provider Demographics
NPI:1790788214
Name:FORTENBERRY, DAMON (CRNA)
Entity Type:Individual
Prefix:
First Name:DAMON
Middle Name:
Last Name:FORTENBERRY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-765-5727
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:433 PLAZA ST
Practice Address - Street 2:
Practice Address - City:BOGALUSA
Practice Address - State:LA
Practice Address - Zip Code:70427-3729
Practice Address - Country:US
Practice Address - Phone:985-730-6700
Practice Address - Fax:985-730-6713
Is Sole Proprietor?:No
Enumeration Date:2005-05-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN073334367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1107042Medicaid
LA1107042Medicaid
LA4B903Medicare PIN
LA430067833Medicare PIN