Healthcare Provider Details

I. General information

NPI: 1881802148
Provider Name (Legal Business Name): MITZI CAROLINA FOGG R.N., M.S.N., F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 E COTATI AVE
ROHNERT PARK CA
94928-3609
US

IV. Provider business mailing address

3538 SKILLMAN LN
PETALUMA CA
94952-1208
US

V. Phone/Fax

Practice location:
  • Phone: 707-664-2921
  • Fax: 707-664-2925
Mailing address:
  • Phone: 415-827-0767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number633049
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: