Basic Information
| Provider Information | |||||||||
| NPI: | 1780715979 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORLIVIO | ||||||||
| FirstName: | JOHANNA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 CLOCK TOWER CMNS | ||||||||
| Address2: | |||||||||
| City: | BREWSTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105094055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455924915 | ||||||||
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| Practice Location | |||||||||
| Address1: | 159 BARNEGAT RD | ||||||||
| Address2: | |||||||||
| City: | POUGHKEEPSIE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8454529800 | ||||||||
| FaxNumber: | 8454527691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 07/24/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 011693 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 02959171 | 05 | NY | MEDICAID |