Provider Demographics
NPI:1982292116
Name:FORST, COLLEEN (PMHNP)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:FORST
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20280 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:ONANCOCK
Mailing Address - State:VA
Mailing Address - Zip Code:23417-1331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17068 LANKFORD HWY
Practice Address - Street 2:
Practice Address - City:EASTVILLE
Practice Address - State:VA
Practice Address - Zip Code:23347
Practice Address - Country:US
Practice Address - Phone:757-331-1086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-04
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001251712163W00000X
VA0024180881363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse