Provider Demographics
NPI:1629047451
Name:BERG-AUDETTE, NANCY A (NP)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:A
Last Name:BERG-AUDETTE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:JONES
Other - Last Name:BERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1441 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2837
Mailing Address - Country:US
Mailing Address - Phone:602-495-4577
Mailing Address - Fax:602-417-3549
Practice Address - Street 1:1901 10TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80639-5545
Practice Address - Country:US
Practice Address - Phone:970-351-2412
Practice Address - Fax:970-350-4953
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO65423363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner