Provider Demographics
NPI:1417944455
Name:BERGERON, AMY (FNP)
Entity Type:Individual
Prefix:
First Name:AMY
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 1:126 SHAKER RD
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:ME
Mailing Address - Zip Code:04039-9629
Mailing Address - Country:US
Mailing Address - Phone:207-657-3308
Mailing Address - Fax:
Practice Address - Street 1:190 STETSON RD
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-7813
Practice Address - Country:US
Practice Address - Phone:207-784-7388
Practice Address - Fax:207-795-2043
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP81508363LF0000X
MEAP081508363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME266180099Medicaid
ME266180099Medicaid