Healthcare Provider Details

I. General information

NPI: 1922476878
Provider Name (Legal Business Name): ELISA BERGQUIST NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELISA LAWSON

II. Dates (important events)

Enumeration Date: 09/09/2015
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 LEGACY PLZ W
LA PORTE IN
46350-5254
US

IV. Provider business mailing address

401 NEWPORTE BLVD
LA PORTE IN
46350-2479
US

V. Phone/Fax

Practice location:
  • Phone: 219-326-0943
  • Fax: 219-326-5684
Mailing address:
  • Phone: 219-575-6244
  • Fax: 219-380-0757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71005757A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: