Healthcare Provider Details

I. General information

NPI: 1639248545
Provider Name (Legal Business Name): FORREST JUNE FOGELBERG CRNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 NAN CT
SANTA MARIA CA
93454-3151
US

IV. Provider business mailing address

910 NAN CT
SANTA MARIA CA
93454-3151
US

V. Phone/Fax

Practice location:
  • Phone: 805-614-4023
  • Fax:
Mailing address:
  • Phone: 805-614-4023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number388276
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: