Provider Demographics
NPI:1306351911
Name:FOGLE, TAKEYA RENEE (NP-C)
Entity type:Individual
Prefix:
First Name:TAKEYA
Middle Name:RENEE
Last Name:FOGLE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:TAKEYA
Other - Middle Name:RENEE
Other - Last Name:SHEPHERD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:706-295-5331
Mailing Address - Fax:
Practice Address - Street 1:14 CHEROKEE RD
Practice Address - Street 2:
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-4381
Practice Address - Country:US
Practice Address - Phone:770-749-9600
Practice Address - Fax:770-749-9628
Is Sole Proprietor?:No
Enumeration Date:2017-12-05
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN193378363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner