Provider Demographics
NPI:1306027891
Name:FORSBERG, IMELDA N (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:IMELDA
Middle Name:N
Last Name:FORSBERG
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6925 184TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:WI
Mailing Address - Zip Code:53104
Mailing Address - Country:US
Mailing Address - Phone:262-948-1890
Mailing Address - Fax:
Practice Address - Street 1:6430 GREENBAY RD
Practice Address - Street 2:SUITE 104
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2948
Practice Address - Country:US
Practice Address - Phone:262-925-0535
Practice Address - Fax:262-925-0538
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-26
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.006867363LA2200X
WI4854363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4854-33OtherSTATE LICENSE