Provider Demographics
NPI:1275867590
Name:BERGERON, KIMBERLY (FNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BERGERON
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 1:1250 S CLEARVIEW AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-3378
Mailing Address - Country:US
Mailing Address - Phone:480-988-9108
Mailing Address - Fax:480-813-4460
Practice Address - Street 1:3611 N CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-1534
Practice Address - Country:US
Practice Address - Phone:520-881-0636
Practice Address - Fax:520-881-0637
Is Sole Proprietor?:No
Enumeration Date:2009-09-21
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3404363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ465975Medicaid
Z169168OtherMEDICARE PTAN
AZ465975OtherAHCCCS
AZZ133723OtherMEDICARE PTAN