=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740789049
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LESLIE BERGER APN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2018
-----------------------------------------------------
Last Update Date | 06/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 WEST MAIN STREET AMBULATORY CAMPUS SUITE 100
-----------------------------------------------------
City | FREEHOLD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-294-2574
-----------------------------------------------------
Fax | 732-294-2575
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 901 WEST MAIN STREET AMBULATORY CAMPUS SUITE 100
-----------------------------------------------------
City | FREEHOLD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-294-2574
-----------------------------------------------------
Fax | 732-294-2575
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | 26NJ00771600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------