Healthcare Provider Details

I. General information

NPI: 1447811534
Provider Name (Legal Business Name): NELVIN GLENN BERGONIA ISON CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2019
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 E PULASKI HWY
ELKTON MD
21921-6435
US

IV. Provider business mailing address

104 PLUMTREE RD
BEL AIR MD
21015-6095
US

V. Phone/Fax

Practice location:
  • Phone: 443-485-6213
  • Fax: 443-485-6226
Mailing address:
  • Phone: 410-515-4300
  • Fax: 410-601-1052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR176504
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR176504
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR176504
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberLG-0012948
License Number StateDE
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberLG-0012948
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: