Provider Demographics
NPI:1235117557
Name:BERGER, MARY KAY (LNP)
Entity Type:Individual
Prefix:
First Name:MARY KAY
Middle Name:
Last Name:BERGER
Suffix:
Gender:F
Credentials:LNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 FOXFIRE RD
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-7857
Mailing Address - Country:US
Mailing Address - Phone:276-632-7128
Mailing Address - Fax:
Practice Address - Street 1:24 CLAY ST
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-2810
Practice Address - Country:US
Practice Address - Phone:276-632-7128
Practice Address - Fax:276-632-0127
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024164726363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004945221Medicaid
VA004945221Medicaid
VACO4131Medicare ID - Type UnspecifiedEMPLOYERS GROUP NUMBER
VA500000912Medicare ID - Type Unspecified