Provider Demographics
NPI:1174186878
Name:FORNES, MITZI ANN TIU
Entity Type:Individual
Prefix:
First Name:MITZI ANN
Middle Name:TIU
Last Name:FORNES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10011 LINDA LN APT 2S
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-1334
Mailing Address - Country:US
Mailing Address - Phone:916-280-3259
Mailing Address - Fax:
Practice Address - Street 1:10011 LINDA LN APT 2S
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-1334
Practice Address - Country:US
Practice Address - Phone:916-280-3259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-17
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070023418225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist