Provider Demographics
NPI:1083647275
Name:FORNEHED, MARY LOU CAMERON (ACNP, BC)
Entity Type:Individual
Prefix:MRS
First Name:MARY LOU
Middle Name:CAMERON
Last Name:FORNEHED
Suffix:
Gender:F
Credentials:ACNP, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-1726
Mailing Address - Country:US
Mailing Address - Phone:931-783-5582
Mailing Address - Fax:931-526-6760
Practice Address - Street 1:145 W 4TH ST STE 201
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501
Practice Address - Country:US
Practice Address - Phone:931-783-2143
Practice Address - Fax:931-783-2152
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6081363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78013588Medicaid
TN4026322OtherBLUE CROSS PIN
TN1530878Medicaid
TN4346448OtherBCBS
P94764Medicare UPIN
TN1035I06452Medicare PIN
TN4346448OtherBCBS
TN3349243Medicare PIN
204044OtherBLACK LUNG
TN3374966Medicaid