Provider Demographics
NPI:1588088892
Name:FORNEY, MANITA
Entity type:Individual
Prefix:MRS
First Name:MANITA
Middle Name:
Last Name:FORNEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 S ASPEN CT
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-4703
Mailing Address - Country:US
Mailing Address - Phone:918-857-9537
Mailing Address - Fax:918-251-7835
Practice Address - Street 1:1316 S ASPEN CT
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-4703
Practice Address - Country:US
Practice Address - Phone:918-857-9537
Practice Address - Fax:918-251-7835
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator