Healthcare Provider Details

I. General information

NPI: 1194123729
Provider Name (Legal Business Name): MARK FOGG DCNP, FNP, APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2014
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1019 FLORA VISTA ST
TRINITY FL
34655-7025
US

IV. Provider business mailing address

1019 FLORA VISTA ST
TRINITY FL
34655-7025
US

V. Phone/Fax

Practice location:
  • Phone: 727-698-3963
  • Fax:
Mailing address:
  • Phone: 727-698-3963
  • Fax: 727-698-3963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN2794242
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: