=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184034555
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY BETH VALEK BERGMAN CNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2014
-----------------------------------------------------
Last Update Date | 04/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14121 PARKE LONG CT SUITE 201
-----------------------------------------------------
City | CHANTILLY
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20151-1647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-503-8519
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14121 PARKE LONG CT SUITE 201
-----------------------------------------------------
City | CHANTILLY
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20151-1647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-503-8519
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | APRN.CNP.15082
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | APRN.CNP.15082
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | APRN.CNP.15082
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------