Healthcare Provider Details

I. General information

NPI: 1336614247
Provider Name (Legal Business Name): ANNALISE FORSYTHE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2018
Last Update Date: 11/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E 20TH ST STE 300
CHEYENNE WY
82001-3882
US

IV. Provider business mailing address

800 E 20TH ST STE 300
CHEYENNE WY
82001-3882
US

V. Phone/Fax

Practice location:
  • Phone: 307-633-7444
  • Fax:
Mailing address:
  • Phone: 307-633-7444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number36066
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1825
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: