Healthcare Provider Details

I. General information

NPI: 1275571986
Provider Name (Legal Business Name): CONNIE ANN BERGLUND FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 11/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18452 BUSINESS 13
BRANSON WEST MO
65737-9609
US

IV. Provider business mailing address

PO BOX 4046
SPRINGFIELD MO
65808-4046
US

V. Phone/Fax

Practice location:
  • Phone: 417-272-8911
  • Fax: 417-272-3910
Mailing address:
  • Phone: 417-269-7241
  • Fax: 417-269-7567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number120233
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2017000437
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: