Provider Demographics
NPI:1902992407
Name:FORNEK, DIANE (PTA)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:FORNEK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2560 SPRINGDALE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564
Mailing Address - Country:US
Mailing Address - Phone:630-778-8933
Mailing Address - Fax:
Practice Address - Street 1:2156 DEEP WATER LANE
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564
Practice Address - Country:US
Practice Address - Phone:630-904-5641
Practice Address - Fax:630-904-5661
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant