Provider Demographics
NPI:1376099127
Name:FORMAN, COURTNEY NICOLLE (PMHNP-BC, FNP-C, FPA)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:NICOLLE
Last Name:FORMAN
Suffix:
Gender:F
Credentials:PMHNP-BC, FNP-C, FPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7080 MILL RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2623
Mailing Address - Country:US
Mailing Address - Phone:815-209-8486
Mailing Address - Fax:
Practice Address - Street 1:2823 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61101
Practice Address - Country:US
Practice Address - Phone:815-968-5342
Practice Address - Fax:815-968-4656
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.004073363L00000X
IL209014910363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily