Healthcare Provider Details

I. General information

NPI: 1306369509
Provider Name (Legal Business Name): SARAH R BERGSTROM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SARAH R WINTERS

II. Dates (important events)

Enumeration Date: 07/19/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1703 LOCUST AVE
FAIRMONT WV
26554
US

IV. Provider business mailing address

1703 LOCUST AVE
FAIRMONT WV
26554-1320
US

V. Phone/Fax

Practice location:
  • Phone: 304-366-6100
  • Fax: 304-366-2220
Mailing address:
  • Phone: 304-366-6100
  • Fax: 304-366-2220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPRN83284-NP-C
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberAPRN83284NP
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN83284-NP-C
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: