Provider Demographics
NPI:1558600015
Name:FOGG, DEBORAH A (NP)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:A
Last Name:FOGG
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:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:WA
Mailing Address - Zip Code:99159-0368
Mailing Address - Country:US
Mailing Address - Phone:509-982-2614
Mailing Address - Fax:509-982-2675
Practice Address - Street 1:510 E AMENDE DR
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:WA
Practice Address - Zip Code:99159-7003
Practice Address - Country:US
Practice Address - Phone:509-982-2614
Practice Address - Fax:509-982-2675
Is Sole Proprietor?:No
Enumeration Date:2013-02-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN083436363L00000X
WAAP60749062363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner