Provider Demographics
NPI:1558505743
Name:BERGWERK, MARY LYNN (RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LYNN
Last Name:BERGWERK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5289 MCKANS CV
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-1543
Mailing Address - Country:US
Mailing Address - Phone:901-685-9663
Mailing Address - Fax:
Practice Address - Street 1:3810 WINCHESTER RD
Practice Address - Street 2:SOUTHEAST MENTAL HEALTH CENTER
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38118-6045
Practice Address - Country:US
Practice Address - Phone:901-369-1420
Practice Address - Fax:901-369-1433
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-01
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN153580163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse