Healthcare Provider Details

I. General information

NPI: 1225515273
Provider Name (Legal Business Name): RENEE BERGSTROM APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2018
Last Update Date: 04/06/2020
Certification Date: 04/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 OGDEN AVE
AURORA IL
60504-7597
US

IV. Provider business mailing address

2111 OGDEN AVE
AURORA IL
60504-7597
US

V. Phone/Fax

Practice location:
  • Phone: 630-978-3800
  • Fax: 630-862-3085
Mailing address:
  • Phone: 630-978-3800
  • Fax: 630-978-6791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041-361808
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209018208
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: