Provider Demographics
NPI:1831383728
Name:FORMAN, CAROLYN JEAN (OMD)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:JEAN
Last Name:FORMAN
Suffix:
Gender:F
Credentials:OMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 BROOKLAND CT APT 12
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22602-6181
Mailing Address - Country:US
Mailing Address - Phone:540-550-0306
Mailing Address - Fax:
Practice Address - Street 1:64 SOMERSET BLVD
Practice Address - Street 2:
Practice Address - City:CHARLES TOWN
Practice Address - State:WV
Practice Address - Zip Code:25414-4827
Practice Address - Country:US
Practice Address - Phone:304-728-5066
Practice Address - Fax:304-728-5074
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV96196171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist