Provider Demographics
NPI:1891099552
Name:FORTNER, CINDY GAIL (CRNA)
Entity Type:Individual
Prefix:
First Name:CINDY
Middle Name:GAIL
Last Name:FORTNER
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:PO BOX 771522
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38177-1522
Mailing Address - Country:US
Mailing Address - Phone:901-486-7569
Mailing Address - Fax:901-382-8070
Practice Address - Street 1:1601 NEW CASTLE RD
Practice Address - Street 2:
Practice Address - City:FORREST CITY
Practice Address - State:AR
Practice Address - Zip Code:72335-2218
Practice Address - Country:US
Practice Address - Phone:870-261-0513
Practice Address - Fax:901-382-8070
Is Sole Proprietor?:No
Enumeration Date:2011-01-10
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR103598163W00000X
ARC002999367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1891099552OtherBLUE CROSS BLUE SHIELD
AR205864001Medicaid
AR1891099552OtherTRICARE - SOUTH REGION
AR205864001Medicaid
AR1891099552OtherTRICARE - SOUTH REGION
AR1891099552OtherTRICARE - SOUTH REGION
TNPENDINGMedicaid