Provider Demographics
NPI:1821365545
Name:FORIST, LEONORA S
Entity Type:Individual
Prefix:MS
First Name:LEONORA
Middle Name:S
Last Name:FORIST
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 1:439 S FANCHER ST
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-2614
Mailing Address - Country:US
Mailing Address - Phone:989-772-9356
Mailing Address - Fax:
Practice Address - Street 1:439 S FANCHER ST
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2614
Practice Address - Country:US
Practice Address - Phone:989-772-9356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-23
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF370255232171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor