Provider Demographics
NPI:1003415266
Name:FORTENBERRY, CHRISTIAN (FNP)
Entity type:Individual
Prefix:MRS
First Name:CHRISTIAN
Middle Name:
Last Name:FORTENBERRY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:971 LAKELAND DR STE 557
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4661
Mailing Address - Country:US
Mailing Address - Phone:601-200-4560
Mailing Address - Fax:
Practice Address - Street 1:971 LAKELAND DR STE 557
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4661
Practice Address - Country:US
Practice Address - Phone:601-200-4560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-20
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904008207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine