Provider Demographics
NPI:1700085156
Name:FORRESTER, MARY GORE (APRN)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:GORE
Last Name:FORRESTER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-3617
Mailing Address - Country:US
Mailing Address - Phone:307-745-8445
Mailing Address - Fax:307-745-8445
Practice Address - Street 1:611 S 2ND ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-3617
Practice Address - Country:US
Practice Address - Phone:307-745-8445
Practice Address - Fax:307-745-8445
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MF1027285OtherDEA NUMBER