Healthcare Provider Details

I. General information

NPI: 1306027891
Provider Name (Legal Business Name): IMELDA N FORSBERG NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2007
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6123 GREEN BAY RD STE 120
KENOSHA WI
53142-2927
US

IV. Provider business mailing address

6123 GREEN BAY RD STE 120
KENOSHA WI
53142-2927
US

V. Phone/Fax

Practice location:
  • Phone: 262-358-2954
  • Fax:
Mailing address:
  • Phone: 262-358-2954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number277004152
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4854-33
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number277004152
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4854-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: