Provider Demographics
NPI:1972151769
Name:FORTNER, ADRIENNE GRAEUB (APRN)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:GRAEUB
Last Name:FORTNER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:ADRIENNE
Other - Middle Name:
Other - Last Name:GRAEUB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:638 E COLLEGE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:KY
Mailing Address - Zip Code:40380-2363
Mailing Address - Country:US
Mailing Address - Phone:606-318-3500
Mailing Address - Fax:
Practice Address - Street 1:638 E COLLEGE AVE STE B
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:KY
Practice Address - Zip Code:40380-2363
Practice Address - Country:US
Practice Address - Phone:606-318-3500
Practice Address - Fax:606-318-3503
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-27
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3013555363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100620230Medicaid