Provider Demographics
NPI:1982978532
Name:FORTNER, LORI D (APRN)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:D
Last Name:FORTNER
Suffix:
Gender:F
Credentials:APRN
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 21850
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71903-1850
Mailing Address - Country:US
Mailing Address - Phone:870-867-2175
Mailing Address - Fax:870-867-4050
Practice Address - Street 1:320 LUZERNE ST
Practice Address - Street 2:
Practice Address - City:MOUNT IDA
Practice Address - State:AR
Practice Address - Zip Code:71957-9437
Practice Address - Country:US
Practice Address - Phone:870-867-2175
Practice Address - Fax:870-867-4050
Is Sole Proprietor?:No
Enumeration Date:2012-02-29
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03657363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR190992758Medicaid