Basic Information
| Provider Information | |||||||||
| NPI: | 1902457047 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORTENBERRY | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | R | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 848491 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752848491 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 HILLCREST MEDICAL BLVD | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767128897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542022000 | ||||||||
| FaxNumber: | 2542025651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2019 | ||||||||
| LastUpdateDate: | 10/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LN0005X | AP143827 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal, Critical Care |
No ID Information.