1497057129 NPI number — MARDELLE ANN BERGSTEN LPN

Table of content: MARDELLE ANN BERGSTEN LPN (NPI 1497057129)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497057129 NPI number — MARDELLE ANN BERGSTEN LPN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERGSTEN
Provider First Name:
MARDELLE
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497057129
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12405 SO 218TH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRETNA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-932-2284
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12405 S 218TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRETNA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68028-5987
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-932-2284
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/01/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 164W00000X , with the licence number:  5217 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5217 . This is a "LPN LICESENE NUMBER" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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