MEDICARE: NICOLE LEE BERG-JOHNSON 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	9779-33	WI

General Provider Information

NPI Number	:	1336787126
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE LEE BERG-JOHNSON FNP

Provider Business Mailing Address
First Line	:	125 E PINE ST STE C
Second Line	:
City	:	LAKE MILLS
State	:	WI
Zip	:	53551-1103
Country	:	US
Telephone Number	:	920-648-5271
Fax Number	:	920-648-4365

Provider Business Practice Location Address
First Line	:	125 E PINE ST STE C
Second Line	:
City	:	LAKE MILLS
State	:	WI
Zip	:	53551-1103
Country	:	US
Telephone Number	:	920-648-5271
Fax Number	:	920-648-4365

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

Provider Enumeration Date	:	12/12/2019
Last Update Date	:	03/17/2022

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