Provider Demographics
NPI:1780084285
Name:FORNAL, CORY LEE (DPT)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:LEE
Last Name:FORNAL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11130 PARKVIEW CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1735
Mailing Address - Country:US
Mailing Address - Phone:260-266-6221
Mailing Address - Fax:260-458-5733
Practice Address - Street 1:11130 PARKVIEW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845
Practice Address - Country:US
Practice Address - Phone:260-266-6221
Practice Address - Fax:260-458-5733
Is Sole Proprietor?:No
Enumeration Date:2014-09-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05011468A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist