Provider Demographics
NPI:1073549069
Name:BERGMAN, NIKKI
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6956 WILLOW HWY
Mailing Address - Street 2:
Mailing Address - City:GRAND LEDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48837-8974
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6512 CENTURION DR STE 340
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-8248
Practice Address - Country:US
Practice Address - Phone:517-323-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000448237600000X
MI3501002065237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP42390002Medicare PIN