Healthcare Provider Details

I. General information

NPI: 1114490224
Provider Name (Legal Business Name): KYLE T BERGAN DNP, APRN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2019
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5875 E RIVERSIDE BLVD
ROCKFORD IL
61114-4937
US

IV. Provider business mailing address

1700 W SUMMERDALE AVE APT BSMT
CHICAGO IL
60640-2068
US

V. Phone/Fax

Practice location:
  • Phone: 815-398-9491
  • Fax: 815-381-7498
Mailing address:
  • Phone: 217-714-4713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209017205
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209017205
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number28268975A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704285087
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ000891500
License Number StateNJ
# 6
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71011442A
License Number StateIN
# 7
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR20578200
License Number StateNJ
# 8
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number041389716
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: