Provider Demographics
NPI:1851996268
Name:FORSTROM, GERALD DONALD JR (RN, BSN)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:DONALD
Last Name:FORSTROM
Suffix:JR
Gender:M
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53536-1331
Mailing Address - Country:US
Mailing Address - Phone:608-698-1923
Mailing Address - Fax:
Practice Address - Street 1:113 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:WI
Practice Address - Zip Code:53536-1331
Practice Address - Country:US
Practice Address - Phone:608-698-1923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI224350-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse