Healthcare Provider Details

I. General information

NPI: 1730727108
Provider Name (Legal Business Name): AVNI BERGUM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2019
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2109 HAMILTON RD STE 217
OKEMOS MI
48864-1700
US

IV. Provider business mailing address

2109 HAMILTON RD STE 217
OKEMOS MI
48864-1700
US

V. Phone/Fax

Practice location:
  • Phone: 517-580-0575
  • Fax: 517-917-0826
Mailing address:
  • Phone: 517-580-0575
  • Fax: 517-917-0826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704293729
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: