Basic Information
| Provider Information | |||||||||
| NPI: | 1376116749 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORTUNE | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | LEA | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 E MCBEE AVE FL 4 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645228603 | ||||||||
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| Practice Location | |||||||||
| Address1: | 22725 HIGHWAY 76 EAST | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293257527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648339100 | ||||||||
| FaxNumber: | 8648339458 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2021 | ||||||||
| LastUpdateDate: | 01/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 68225 | SC | N | Nursing Service Providers | Registered Nurse | 363L00000X | 25295 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | SC | MEDICAID |