Provider Demographics
NPI:1134559610
Name:SMITH-FORNSHELL, STEPHANIE L (CNP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:SMITH-FORNSHELL
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:L
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 W BURNSVILLE PKWY STE 207
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-0010
Mailing Address - Country:US
Mailing Address - Phone:612-548-4266
Mailing Address - Fax:952-686-6966
Practice Address - Street 1:101 W BURNSVILLE PKWY STE 207
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-0010
Practice Address - Country:US
Practice Address - Phone:612-548-4266
Practice Address - Fax:952-686-6966
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-19
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2759363LP0808X
MNR1908376363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty