Provider Demographics
NPI:1780087213
Name:FORKA, AUDREY (MSN,PMHNP-BC)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:FORKA
Suffix:
Gender:F
Credentials:MSN,PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S UNION AVE
Mailing Address - Street 2:BEHAVIORAL HEALTH UNIT
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-3409
Mailing Address - Country:US
Mailing Address - Phone:609-598-2298
Mailing Address - Fax:
Practice Address - Street 1:611 S UNION AVE
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-3421
Practice Address - Country:US
Practice Address - Phone:443-526-6133
Practice Address - Fax:443-526-6134
Is Sole Proprietor?:No
Enumeration Date:2014-09-29
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC001470363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health