Provider Demographics
NPI:1235289034
Name:FOGG, TONJA MYSHAWNE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:TONJA
Middle Name:MYSHAWNE
Last Name:FOGG
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:MYSHAWNE
Other - Middle Name:
Other - Last Name:FOGG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:3113 GREGGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37207-2707
Mailing Address - Country:US
Mailing Address - Phone:615-876-9874
Mailing Address - Fax:
Practice Address - Street 1:1310 24TH AVE S
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37212-2637
Practice Address - Country:US
Practice Address - Phone:615-327-4751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPN0000066910164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0000066910OtherLPN