Provider Demographics
NPI:1124393905
Name:BERGQUIST, BRIANNE D
Entity Type:Individual
Prefix:MISS
First Name:BRIANNE
Middle Name:D
Last Name:BERGQUIST
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 1:221 E ALTENA AVE
Mailing Address - Street 2:
Mailing Address - City:DE QUEEN
Mailing Address - State:AR
Mailing Address - Zip Code:71832-2673
Mailing Address - Country:US
Mailing Address - Phone:870-774-0920
Mailing Address - Fax:870-774-0926
Practice Address - Street 1:1202 N STATELINE AVE
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-4969
Practice Address - Country:US
Practice Address - Phone:870-774-0920
Practice Address - Fax:870-774-0926
Is Sole Proprietor?:No
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator