Provider Demographics
NPI:1942359757
Name:VARDELL, BERGEN CHRISTINE (WHNP, CNM)
Entity Type:Individual
Prefix:MS
First Name:BERGEN
Middle Name:CHRISTINE
Last Name:VARDELL
Suffix:
Gender:F
Credentials:WHNP, CNM
Other - Prefix:MS
Other - First Name:BERGEN
Other - Middle Name:CHRISTINE
Other - Last Name:MAHONEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:WHNP, CNM
Mailing Address - Street 1:4515 SETON CENTER PKWY STE 215
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5785
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12174 N MOPAC EXPY STE A
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-2910
Practice Address - Country:US
Practice Address - Phone:512-994-2662
Practice Address - Fax:512-406-6202
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2017-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY31936.1243367A00000X
TXAP115623367A00000X
WV176367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810023250Medicaid
WVQ39412CMedicare PIN
WVQ39412AMedicare PIN
WV3810023250Medicaid
WVQ39412EMedicare PIN
WVQ39412DMedicare PIN