Basic Information
| Provider Information | |||||||||
| NPI: | 1750043311 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORTENBERRY | ||||||||
| FirstName: | KAYLA | ||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1923 SULPHUR SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | MORRISTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378135654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233179344 | ||||||||
| FaxNumber: | 4237142355 | ||||||||
| Practice Location | |||||||||
| Address1: | 1596 HIGHWAY 33 S | ||||||||
| Address2: | |||||||||
| City: | NEW TAZEWELL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378257104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236268271 | ||||||||
| FaxNumber: | 8653420106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2021 | ||||||||
| LastUpdateDate: | 10/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 90639 | TN | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.