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Individual

GRACE JEAN FORNWALT

Active
Sole proprietor
No

Provider details

NPI number
Gender
F
Credential
MHR, ATC, LAT, CES

Contact information

Practice address
375 TRIAD VILLAGE DR UNIT 14, NORMAN, OK 73071-2896
(314) 753-6506
Mailing address
375 TRIAD VILLAGE DR UNIT 14, NORMAN, OK 73071-2896
(314) 753-6506

Taxonomy

Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
2015032686
MO
2255A2300X
Athletic Trainer
Primary
987
OK
2255A2300X
Athletic Trainer
TX

Other

Enumeration date
04/22/2019
Last updated
04/22/2019
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