Healthcare Provider Details

I. General information

NPI: 1801736665
Provider Name (Legal Business Name): MISTY MICHELLE FORNESS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2026
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8210 FAWN LAKE DR NE
STACY MN
55079-9322
US

IV. Provider business mailing address

8210 FAWN LAKE DR NE
STACY MN
55079-9322
US

V. Phone/Fax

Practice location:
  • Phone: 612-725-8080
  • Fax:
Mailing address:
  • Phone: 612-725-8080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR-1483008
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: