Provider Demographics
NPI:1639210412
Name:BERG, SUSAN L (FNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name: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 1:2995 DREW ST FL 2
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-3012
Mailing Address - Country:US
Mailing Address - Phone:727-315-7496
Mailing Address - Fax:
Practice Address - Street 1:3503 E FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-1742
Practice Address - Country:US
Practice Address - Phone:813-586-8187
Practice Address - Fax:813-321-6998
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO150718363LF0000X, 363LP2300X
FLAPRN9432283363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO428420509Medicaid
AR159889758OtherAR MDCD #
MO428420509Medicaid
AR159889758OtherAR MDCD #