Provider Demographics
NPI:1003570680
Name:FORKNER, MOLLY (RD)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:FORKNER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 ROCK CHALK DR APT 13308
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-5054
Mailing Address - Country:US
Mailing Address - Phone:541-207-2256
Mailing Address - Fax:
Practice Address - Street 1:5401 ROCK CHALK DR APT 13308
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-5054
Practice Address - Country:US
Practice Address - Phone:541-207-2256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered