Provider Demographics
NPI:1518570118
Name:BERGEN, STEPHANIE P (MS RD CD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:P
Last Name:BERGEN
Suffix:
Gender:F
Credentials:MS RD CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1132 E BRYAN AVE APT A
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-2508
Mailing Address - Country:US
Mailing Address - Phone:802-310-0068
Mailing Address - Fax:
Practice Address - Street 1:1132 E BRYAN AVE APT A
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-2508
Practice Address - Country:US
Practice Address - Phone:802-310-0068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered