=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306027891
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IMELDA N FORSBERG NURSE PRACTITIONER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2007
-----------------------------------------------------
Last Update Date | 02/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6430 GREENBAY RD SUITE 104
-----------------------------------------------------
City | KENOSHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53142-2948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-925-0535
-----------------------------------------------------
Fax | 262-925-0538
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6925 184TH AVENUE
-----------------------------------------------------
City | BRISTOL
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-948-1890
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 209.006867
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | PMH08240049
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 4854
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------