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NPI Code Detail

MEDICARE: RY WILLIS BERGUM PMHNP

MEDICARE: RY WILLIS BERGUM PMHNP
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
1363LP0808XPsychiatric/Mental Health Nurse Practitioner0024181720VA

General Provider Information

NPI Number : 1275103459
Entity Type Code : Individual
Provider Name (Legal Business Name) : RY WILLIS BERGUM PMHNP
Provider Business Mailing Address
First Line : 12300 WASHINGTON HWY
Second Line :
City : ASHLAND
State : VA
Zip : 23005-7646
Country : US
Telephone Number : 804-365-4200
Fax Number :
Provider Business Practice Location Address
First Line : 12300 WASHINGTON HWY
Second Line :
City : ASHLAND
State : VA
Zip : 23005-7646
Country : US
Telephone Number : 804-365-4200
Fax Number : 804-365-6639
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/29/2021
Last Update Date : 12/09/2025

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