Provider Demographics
NPI:1518520931
Name:FORNWALT, GRACE JEAN (MHR, ATC, LAT, CES)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:JEAN
Last Name:FORNWALT
Suffix:
Gender:F
Credentials:MHR, ATC, LAT, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 TRIAD VILLAGE DR UNIT 14
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-2896
Mailing Address - Country:US
Mailing Address - Phone:314-753-6506
Mailing Address - Fax:
Practice Address - Street 1:375 TRIAD VILLAGE DR UNIT 14
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-2896
Practice Address - Country:US
Practice Address - Phone:314-753-6506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-22
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20150326862255A2300X
TX2255A2300X
OK9872255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer