Provider Demographics
NPI:1992184956
Name:BERGGREN, ANNE MARIE (RDN, CNSC)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:MARIE
Last Name:BERGGREN
Suffix:
Gender:F
Credentials:RDN, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 CLEMATIS ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1802
Mailing Address - Country:US
Mailing Address - Phone:631-560-4466
Mailing Address - Fax:
Practice Address - Street 1:22 CLEMATIS ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1802
Practice Address - Country:US
Practice Address - Phone:631-560-4466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-23
Last Update Date:2015-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY941958133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered