Provider Demographics
NPI:1194123679
Name:FORNER, JUDI KITTLE
Entity type:Individual
Prefix:
First Name:JUDI
Middle Name:KITTLE
Last Name:FORNER
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JUDI
Other - Middle Name:LYNNE
Other - Last Name:KITTLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN, ACNS, RN
Mailing Address - Street 1:4309 W MEDICAL CENTER DR STE A200
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-8437
Mailing Address - Country:US
Mailing Address - Phone:815-759-8070
Mailing Address - Fax:815-759-4931
Practice Address - Street 1:4309 W MEDICAL CENTER DR STE A200
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050
Practice Address - Country:US
Practice Address - Phone:815-759-8070
Practice Address - Fax:815-759-4931
Is Sole Proprietor?:No
Enumeration Date:2014-12-15
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010514364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209010514OtherSTATE LICENSE