Provider Demographics
NPI:1295471019
Name:BERG, KACI MICHELLE
Entity Type:Individual
Prefix:
First Name:KACI
Middle Name:MICHELLE
Last Name:BERG
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 1:3100 33RD ST S APT 108
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-7826
Mailing Address - Country:US
Mailing Address - Phone:701-238-1086
Mailing Address - Fax:
Practice Address - Street 1:3100 33RD ST S APT 108
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-7826
Practice Address - Country:US
Practice Address - Phone:701-238-1086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program