Provider Demographics
NPI:1508446089
Name:PORTER BERG, SKYE RAELYNN (FNP)
Entity Type:Individual
Prefix:
First Name:SKYE
Middle Name:RAELYNN
Last Name:PORTER BERG
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 1:1300 ETHAN WAY STE 600
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-2296
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2825 CAPITOL AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-6039
Practice Address - Country:US
Practice Address - Phone:916-887-1310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-09
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95223197163WE0003X
CA95019889207RI0011X, 363LC0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL00000Medicaid
CA2211IMAAMedicaid