Healthcare Provider Details

I. General information

NPI: 1609441609
Provider Name (Legal Business Name): SHAMIR BERGERON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2021
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 LAKE LUCIEN DR STE 112
MAITLAND FL
32751-7233
US

IV. Provider business mailing address

PO BOX 40549
BELFAST ME
04915-1256
US

V. Phone/Fax

Practice location:
  • Phone: 248-266-4200
  • Fax:
Mailing address:
  • Phone: 321-207-9029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11013119
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: