Keely Fortenberry
Individual provider Active NPI Occupational Therapist · Prentiss, MS
NPI 1336769306 · NPPES record last updated Apr 20, 2020
Key facts
- NPI
- 1336769306
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Occupational Therapist 225X00000X
- License
- OT3495 (MS)
- Practice address
- 1102 Rose St
Prentiss, MS 39474-5200 - Phone
- (601) 792-1242
- NPI assigned
- Apr 20, 2020
- Sex
- Female
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| OT3495 | MS | MD | Occupational Therapist |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Occupational Therapist | 225X00000X | OT3495 | MS | Yes |
Addresses
Primary practice location
1102 Rose St
Prentiss, MS 39474-5200
Mailing address
711 Avignon Dr
Ridgeland, MS 39157-5120
NPI Registry JSON
{
"created_epoch": "1587340800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1587340800000",
"number": "1336769306",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "711 AVIGNON DR",
"city": "RIDGELAND",
"state": "MS",
"postal_code": "391575120"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1102 ROSE ST",
"city": "PRENTISS",
"state": "MS",
"postal_code": "394745200",
"telephone_number": "601-792-1242"
}
],
"practiceLocations": [],
"basic": {
"last_name": "FORTENBERRY",
"first_name": "KEELY",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2020-04-20",
"last_updated": "2020-04-20",
"certification_date": "2020-04-20",
"status": "A"
},
"taxonomies": [
{
"code": "225X00000X",
"taxonomy_group": "",
"desc": "Occupational Therapist",
"state": "MS",
"license": "OT3495",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Prentiss, MS
- Forrest County General Hospital
- Forrest County General Hospital
- Forrest County General Hospital
- Forrest County General Hospital
- Forrest County General Hospital
- Stephanie Gardner
- Kimberly Gholar
- Gregory T Lee
- Renee V Harrien
- Hattiesburg Clinic PA
All providers in Prentiss, MS · Occupational Therapist in Mississippi
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 20, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.