Provider Demographics
NPI:1164669792
Name:BERGIE-MOORE, PHYLLIS (RD)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:BERGIE-MOORE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:
Other - Last Name:VAUGHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LRD
Mailing Address - Street 1:144 STONY POINT RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4122
Mailing Address - Country:US
Mailing Address - Phone:707-521-4649
Mailing Address - Fax:707-521-4628
Practice Address - Street 1:144 STONY POINT RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4122
Practice Address - Country:US
Practice Address - Phone:707-521-4649
Practice Address - Fax:707-521-4628
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic