Provider Demographics
NPI:1043331390
Name:BERG, MARY (FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BERG
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10653 DOUGLAS LN
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-9010
Mailing Address - Country:US
Mailing Address - Phone:530-263-8109
Mailing Address - Fax:
Practice Address - Street 1:10653 DOUGLAS LN
Practice Address - Street 2:
Practice Address - City:NEVADA CITY
Practice Address - State:CA
Practice Address - Zip Code:95959-9010
Practice Address - Country:US
Practice Address - Phone:530-263-8109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP13784363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily