Healthcare Provider Details

I. General information

NPI: 1518390012
Provider Name (Legal Business Name): MOLLY KATHRYN BERGLUND APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2013
Last Update Date: 08/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1270 PRINCE AVE STE 201
ATHENS GA
30606
US

IV. Provider business mailing address

2727 PACES FERRY RD SE STE 1-1100
ATLANTA GA
30339-6151
US

V. Phone/Fax

Practice location:
  • Phone: 706-475-7055
  • Fax:
Mailing address:
  • Phone: 706-475-7055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN175534
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberRN175534
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: