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General NPI Number Information
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NPI Number | 1376099127
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Entity Type | Individual
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Provider Name | COURTNEY NICOLLE FORMAN PMHNP-BC, FNP-C, FPA
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Gender | Female
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Dates
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Enumeration Date | 08/31/2016
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Last Update Date | 04/15/2025
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Provider Practice Location Address
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Address Line | 2823 GLENWOOD AVE
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City | ROCKFORD
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State | IL
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Zip | 61101
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Country | US
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Telephone | 815-968-5342
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Fax | 815-968-4656
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Provider Business Mailing Address
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Address Line | 7080 MILL RD
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City | ROCKFORD
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State | IL
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Zip | 61108-2623
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Country | US
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Telephone | 815-209-8486
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 227.004073
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 209014910
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License Number State | IL
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