Provider Demographics
NPI:1720436546
Name:FOGLE, TAMMY (RN)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:FOGLE
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 1:1117 ASPEN ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-2612
Mailing Address - Country:US
Mailing Address - Phone:951-734-0589
Mailing Address - Fax:
Practice Address - Street 1:245 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-1851
Practice Address - Country:US
Practice Address - Phone:877-251-3669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA123352IV101YA0400X
CA555078163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice