Provider Demographics
NPI:1942741657
Name:FOGELSTROM, WENDY LEE (RN)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:LEE
Last Name:FOGELSTROM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:663 KEOUGH ST
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93514-2533
Mailing Address - Country:US
Mailing Address - Phone:760-872-3417
Mailing Address - Fax:
Practice Address - Street 1:663 KEOUGH ST
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-2533
Practice Address - Country:US
Practice Address - Phone:760-872-3417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-14
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA498896163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse