Provider Demographics
NPI:1821231861
Name:LUNDBERG, BERTINE METAGO (NP)
Entity Type:Individual
Prefix:
First Name:BERTINE
Middle Name:METAGO
Last Name:LUNDBERG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:BERTINE
Other - Middle Name:
Other - Last Name:METAGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:1255 HIGHWAY 54 W
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4526
Mailing Address - Country:US
Mailing Address - Phone:404-367-3014
Mailing Address - Fax:
Practice Address - Street 1:1255 HIGHWAY 54 W
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4526
Practice Address - Country:US
Practice Address - Phone:404-367-3014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-07
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY296527164W00000X
GARN245551363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No164W00000XNursing Service ProvidersLicensed Practical Nurse