Provider Demographics
NPI:1073158986
Name:FORNEY, SHELBY (PNP)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:FORNEY
Suffix:
Gender:F
Credentials:PNP
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 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-777-6435
Mailing Address - Fax:
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-944-2143
Practice Address - Fax:317-944-3107
Is Sole Proprietor?:No
Enumeration Date:2019-11-14
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28236497A163WP0200X
IN71010070B363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300038711Medicaid