Provider Demographics
NPI:1033788427
Name:FORBACH, EVENSTAR AMELIA (DNP)
Entity Type:Individual
Prefix:DR
First Name:EVENSTAR
Middle Name:AMELIA
Last Name:FORBACH
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7510 W BRIDLE TRL
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-8021
Mailing Address - Country:US
Mailing Address - Phone:928-600-1731
Mailing Address - Fax:
Practice Address - Street 1:7510 W BRIDLE TRL
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-8021
Practice Address - Country:US
Practice Address - Phone:928-600-1731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ240186363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care