Provider Demographics
NPI:1952037442
Name:FORNWALT, LAURA JEAN
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JEAN
Last Name:FORNWALT
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 1:5905 O ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-2235
Mailing Address - Country:US
Mailing Address - Phone:402-436-1905
Mailing Address - Fax:
Practice Address - Street 1:1835 PAWNEE ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68502-4646
Practice Address - Country:US
Practice Address - Phone:314-288-5565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider