Provider Demographics
NPI:1275571986
Name:BERGLUND, CONNIE ANN (FNP)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:ANN
Last Name:BERGLUND
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-7241
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:18452 BUSINESS 13
Practice Address - Street 2:
Practice Address - City:BRANSON WEST
Practice Address - State:MO
Practice Address - Zip Code:65737-9609
Practice Address - Country:US
Practice Address - Phone:417-272-8911
Practice Address - Fax:417-272-3910
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO120233363LF0000X
MO2017000437363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO482681YYS0OtherMEDICARE B PTAN FOR MOUNTAIN PEAKS URGENT CARE
P01631094OtherRAILROAD WORKERS MEDICARE PTAN FOR MOUNTAIN PEAKS URGENT CARE
CO70356785Medicaid