MEDICARE: JOHANNYS BERGOLLA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	APRN11038862	FL

General Provider Information

NPI Number	:	1194512467
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHANNYS BERGOLLA

Provider Business Mailing Address
First Line	:	1381 W 30TH ST
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33012-4853
Country	:	US
Telephone Number	:	305-989-5518
Fax Number	:

Provider Business Practice Location Address
First Line	:	1381 W 30TH ST
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33012-4853
Country	:	US
Telephone Number	:	305-989-5518
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/21/2025
Last Update Date	:	04/21/2025

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Directions to “ JOHANNYS BERGOLLA ” Practice Location

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