Healthcare Provider Details

I. General information

NPI: 1417125493
Provider Name (Legal Business Name): FATU MONIQUE FORNA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N OAK AVE
MARSHFIELD WI
54449-5703
US

IV. Provider business mailing address

3495 PIEDMONT RD NE
ATLANTA GA
30305-1717
US

V. Phone/Fax

Practice location:
  • Phone: 715-387-5511
  • Fax:
Mailing address:
  • Phone: 404-364-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number15585
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number051937
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME168411
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: