Provider Demographics
NPI:1114066271
Name:BERGSMA, AUDREY LEE (ND)
Entity Type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:LEE
Last Name:BERGSMA
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 SW 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5003
Mailing Address - Country:US
Mailing Address - Phone:503-552-1590
Mailing Address - Fax:503-226-8133
Practice Address - Street 1:2220 SW 1ST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-5003
Practice Address - Country:US
Practice Address - Phone:503-552-1590
Practice Address - Fax:503-226-8133
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR871175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath