Provider Demographics
NPI:1881802148
Name:FOGG, MITZI CAROLINA (RN, MSN, FNP)
Entity type:Individual
Prefix:
First Name:MITZI
Middle Name:CAROLINA
Last Name:FOGG
Suffix:
Gender:F
Credentials:RN, MSN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3538 SKILLMAN LN
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-1208
Mailing Address - Country:US
Mailing Address - Phone:415-827-0767
Mailing Address - Fax:
Practice Address - Street 1:1801 E COTATI AVE
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-3609
Practice Address - Country:US
Practice Address - Phone:707-664-2921
Practice Address - Fax:707-664-2925
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA633049363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1881802148Medicaid