Provider Demographics
NPI:1457630428
Name:FORSBERG, NICOLE (NP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:FORSBERG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 S UTICA AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4000
Mailing Address - Country:US
Mailing Address - Phone:918-579-3130
Mailing Address - Fax:918-579-3139
Practice Address - Street 1:1145 S UTICA AVE
Practice Address - Street 2:STE 202
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4000
Practice Address - Country:US
Practice Address - Phone:918-579-3130
Practice Address - Fax:918-579-3139
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPN001309363L00000X
OK65929363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner