Provider Demographics
NPI:1750774691
Name:FORNWALT, RACHAEL ANN (CRNP)
Entity type:Individual
Prefix:
First Name:RACHAEL
Middle Name:ANN
Last Name:FORNWALT
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12030 LITTLE PATUXENT PKWY APT P
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-4817
Mailing Address - Country:US
Mailing Address - Phone:814-934-1012
Mailing Address - Fax:
Practice Address - Street 1:12030 LITTLE PATUXENT PKWY APT P
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-4817
Practice Address - Country:US
Practice Address - Phone:814-934-1012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-17
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR201859163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse