1790814747 NPI number — MISS VICTORIA TERESA FORTNER III

Table of content: MISS VICTORIA TERESA FORTNER III (NPI 1790814747)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790814747 NPI number — MISS VICTORIA TERESA FORTNER III

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORTNER
Provider First Name:
VICTORIA
Provider Middle Name:
TERESA
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
III
Provider Credential Text:
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:
1790814747
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12100 FIELDSTONE LN APT M65
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRYANT
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72022-6257
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-350-4239
Provider Business Mailing Address Fax Number:
501-594-5244

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12100 FIELDSTONE LN APT M65
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRYANT
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72022-6257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-594-5200
Provider Business Practice Location Address Fax Number:
501-594-5244
Provider Enumeration Date:
03/05/2007

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: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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