MEDICARE: CONNIE ANN BERGLUND FNP

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	363LF0000X	Family Nurse Practitioner	120233	CO
2	363LF0000X	Family Nurse Practitioner	2017000437	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	482681YYS0	OTHER	CO	MEDICARE B PTAN FOR MOUNTAIN PEAKS URGENT CARE
2	P01631094	OTHER		RAILROAD WORKERS MEDICARE PTAN FOR MOUNTAIN PEAKS URGENT CARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275571986
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONNIE ANN BERGLUND FNP

Provider Business Mailing Address
First Line	:	PO BOX 4046
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65808-4046
Country	:	US
Telephone Number	:	417-269-7241
Fax Number	:	417-269-7567

Provider Business Practice Location Address
First Line	:	18452 BUSINESS 13
Second Line	:
City	:	BRANSON WEST
State	:	MO
Zip	:	65737-9609
Country	:	US
Telephone Number	:	417-272-8911
Fax Number	:	417-272-3910

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

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	11/14/2018

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