1730586991 NPI number — AMANDA FORTUNE CNM

Table of content: AMANDA FORTUNE CNM (NPI 1730586991)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730586991 NPI number — AMANDA FORTUNE CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORTUNE
Provider First Name:
AMANDA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730586991
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
530 DUVAL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUMA
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70364-3102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-201-1900
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
530 DUVAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUMA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70364-3102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-201-1900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/03/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207VX0000X , with the licence number:  AP08064 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163WW0101X , with the licence number: RN126526 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CNM2337 . This is a "AMCB" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00338278 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: RN126526 . This is a "LSBN" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: AP08064 . This is a "LSBN" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 2382063 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".