Provider Demographics
NPI:1679564215
Name:FOSTER, MARILYN W (FNP)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:W
Last Name:FOSTER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 GRAVENSTEIN HWY, N, #161
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472
Mailing Address - Country:US
Mailing Address - Phone:707-829-0703
Mailing Address - Fax:
Practice Address - Street 1:854 FERGUSON RD
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-9666
Practice Address - Country:US
Practice Address - Phone:707-799-0421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN169169163W00000X, 163WG0600X
CANP294363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No163WG0600XNursing Service ProvidersRegistered NurseGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP000294Medicaid
2005453181OtherCWCN
CANP0002940Medicaid
CANP0002940Medicaid
CAQ60199Medicare UPIN
CANP000294Medicaid