Healthcare Provider Details

I. General information

NPI: 1487807848
Provider Name (Legal Business Name): ANNIKA JEANETTE BERGESON MSN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2008
Last Update Date: 10/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1739 E BEVERLY AVE SUITE 106
KINGMAN AZ
86409-3593
US

IV. Provider business mailing address

1739 E BEVERLY AVE SUITE 106
KINGMAN AZ
86409-3593
US

V. Phone/Fax

Practice location:
  • Phone: 928-757-3133
  • Fax: 928-757-3136
Mailing address:
  • Phone: 928-757-3133
  • Fax: 928-757-3136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP3049
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: