Provider Demographics
NPI:1225515273
Name:BERGSTROM, RENEE (APN)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-7597
Mailing Address - Country:US
Mailing Address - Phone:630-978-3800
Mailing Address - Fax:630-978-6791
Practice Address - Street 1:2111 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-7597
Practice Address - Country:US
Practice Address - Phone:630-978-3800
Practice Address - Fax:630-862-3085
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-361808163W00000X
IL209018208363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse