Healthcare Provider Details

I. General information

NPI: 1790697688
Provider Name (Legal Business Name): SOPHIA MARY FORNICOLA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 W BOWERY ST
AKRON OH
44308-1046
US

IV. Provider business mailing address

1036 BENNINGTON AVE NE
MASSILLON OH
44646-4460
US

V. Phone/Fax

Practice location:
  • Phone: 330-543-8224
  • Fax:
Mailing address:
  • Phone: 330-819-8930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number50.010635RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: