Provider Demographics
NPI:1780715979
Name:FORLIVIO, JOHANNA M (PA)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:M
Last Name:FORLIVIO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 CLOCK TOWER CMNS
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509-4055
Mailing Address - Country:US
Mailing Address - Phone:845-592-4915
Mailing Address - Fax:
Practice Address - Street 1:159 BARNEGAT RD
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601
Practice Address - Country:US
Practice Address - Phone:845-452-9800
Practice Address - Fax:845-452-7691
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011693363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02959171Medicaid