Provider Demographics
NPI:1295214864
Name:BERGLUND, SHELLY (LVN)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:BERGLUND
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 ETOWAH DR
Mailing Address - Street 2:
Mailing Address - City:HARKER HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:76548-5501
Mailing Address - Country:US
Mailing Address - Phone:254-833-7545
Mailing Address - Fax:
Practice Address - Street 1:504 ETOWAH DR
Practice Address - Street 2:
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-5501
Practice Address - Country:US
Practice Address - Phone:254-833-7545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX337249164W00000X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse