Healthcare Provider Details

I. General information

NPI: 1780159145
Provider Name (Legal Business Name): ANDREA L BERGELEEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2018
Last Update Date: 08/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3914 MURPHY CANYON RD STE A138
SAN DIEGO CA
92123-4469
US

IV. Provider business mailing address

5711 WATER ST APT 9
LA MESA CA
91942-4150
US

V. Phone/Fax

Practice location:
  • Phone: 619-948-8063
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberLM578
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: