Provider Demographics
NPI:1083190326
Name:FORNONI, ELIZABETH AMELIA
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:AMELIA
Last Name:FORNONI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:AMELIA
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8748 N MINGO RD APT 1120
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-5076
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11740 E 21ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74129-1820
Practice Address - Country:US
Practice Address - Phone:918-437-9495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6270104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker