Provider Demographics
NPI:1912559907
Name:BERGMAN, JODI (RN)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:BERGMAN
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 1:2636 BELMILL RD
Mailing Address - Street 2:
Mailing Address - City:BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-4513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2636 BELMILL RD
Practice Address - Street 2:
Practice Address - City:BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-4513
Practice Address - Country:US
Practice Address - Phone:516-567-6516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY712649163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse