Provider Demographics
NPI:1093183642
Name:BERGEN, KELLY MARIE (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:BERGEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:NAVARRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2555 COURT DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2134
Mailing Address - Country:US
Mailing Address - Phone:704-868-3256
Mailing Address - Fax:704-868-5870
Practice Address - Street 1:2555 COURT DR
Practice Address - Street 2:SUITE 300
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2134
Practice Address - Country:US
Practice Address - Phone:704-868-3256
Practice Address - Fax:704-868-5870
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-11
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC162782363LA2100X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology