Provider Demographics
NPI:1225631427
Name:BERGEN, DONNA LYNN
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:LYNN
Last Name:BERGEN
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 1:1702 STATE ROUTE 28
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:OH
Mailing Address - Zip Code:45148-9703
Mailing Address - Country:US
Mailing Address - Phone:937-728-3219
Mailing Address - Fax:
Practice Address - Street 1:1702 STATE ROUTE 28
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:OH
Practice Address - Zip Code:45148-9703
Practice Address - Country:US
Practice Address - Phone:937-728-3219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant