Provider Demographics
NPI:1265694715
Name:FORLITI, BREANN MARIE (OD)
Entity type:Individual
Prefix:MRS
First Name:BREANN
Middle Name:MARIE
Last Name:FORLITI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 KENWOOD ST S
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:55008-2640
Mailing Address - Country:US
Mailing Address - Phone:763-689-4397
Mailing Address - Fax:
Practice Address - Street 1:12170 ABERDEEN ST NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-4716
Practice Address - Country:US
Practice Address - Phone:763-757-7000
Practice Address - Fax:763-757-3328
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3121152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1265694715Medicaid
MN1265694715Medicare NSC
MN1265694715Medicare PIN