MEDICARE: DESTENY GRACE BERGDOLL RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WS0200X	School Registered Nurse	287895	AZ

General Provider Information

NPI Number	:	1346072071
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTENY GRACE BERGDOLL RN

Provider Business Mailing Address
First Line	:	1817 N 7TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85006-2133
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	811 N 13TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85006-3400
Country	:	US
Telephone Number	:	602-257-3865
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2024
Last Update Date	:	08/20/2024

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