=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366379950
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIRANDA BERGMANN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2026
-----------------------------------------------------
Last Update Date | 05/06/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1111 6TH AVE
-----------------------------------------------------
City | DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50314-2613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-247-3121
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 242 1ST ST
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52731-9684
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | A189279
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------