Provider Demographics
NPI:1134519077
Name:MADE WHOLE HEALTHCARE SOLUTIONS, INC
Entity type:Organization
Organization Name:MADE WHOLE HEALTHCARE SOLUTIONS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:NEDRA
Authorized Official - Middle Name:S
Authorized Official - Last Name:FORTSON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:770-330-8496
Mailing Address - Street 1:PO BOX 71802
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31708-1802
Mailing Address - Country:US
Mailing Address - Phone:770-330-8496
Mailing Address - Fax:229-888-7421
Practice Address - Street 1:2709 GILLIONVILLE RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31721-6271
Practice Address - Country:US
Practice Address - Phone:229-483-0020
Practice Address - Fax:229-483-0021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-30
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363LA2200X
GARN131505261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA217951Medicaid
GA20250I9514OtherMEDICARE PTAN