Provider Demographics
NPI:1639248545
Name:FOGELBERG, FORREST JUNE (CRNFA)
Entity Type:Individual
Prefix:MRS
First Name:FORREST
Middle Name:JUNE
Last Name:FOGELBERG
Suffix:
Gender:F
Credentials:CRNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 NAN CT
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-3151
Mailing Address - Country:US
Mailing Address - Phone:805-614-4023
Mailing Address - Fax:
Practice Address - Street 1:910 NAN CT
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-3151
Practice Address - Country:US
Practice Address - Phone:805-614-4023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA388276364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist