Provider Demographics
NPI:1053040816
Name:BERKLEY, GINA LEE (AGPCNP-BC)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:LEE
Last Name:BERKLEY
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:LEE
Other - Last Name:CANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1646 VILLA RD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6559
Mailing Address - Country:US
Mailing Address - Phone:248-909-7133
Mailing Address - Fax:
Practice Address - Street 1:1031 SUNCREST DR
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-1136
Practice Address - Country:US
Practice Address - Phone:810-664-4870
Practice Address - Fax:810-664-0921
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704341531163WC0200X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine