Provider Demographics
NPI:1245204247
Name:FORNAROTTO, STACEY (PA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:FORNAROTTO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1754
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18105-1754
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2649 SCHOENERSVILLE RD
Practice Address - Street 2:STE 201
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18017-7326
Practice Address - Country:US
Practice Address - Phone:610-868-6880
Practice Address - Fax:610-868-5333
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMP20000363AM0700X
PAMA002023L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJQ17650Medicare UPIN
NJ080119DECMedicare ID - Type Unspecified