Provider Demographics
NPI:1659567477
Name:KING, STEPHANIE FORNEY
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:FORNEY
Last Name:KING
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 1:4708 TENNILLE CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-8501
Mailing Address - Country:US
Mailing Address - Phone:704-532-4249
Mailing Address - Fax:
Practice Address - Street 1:2300 ABERDEEN BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-0613
Practice Address - Country:US
Practice Address - Phone:704-834-3037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-16
Last Update Date:2007-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2048225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist