Healthcare Provider Details

I. General information

NPI: 1578093266
Provider Name (Legal Business Name): AMANDA BERGMAN MSN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA PICKENS

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 02/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3231 S NATIONAL AVE STE 250
SPRINGFIELD MO
65807-7304
US

IV. Provider business mailing address

3231 S NATIONAL AVE STE 250
SPRINGFIELD MO
65807-7304
US

V. Phone/Fax

Practice location:
  • Phone: 417-885-0827
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2017019296
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: