Provider Demographics
NPI:1013040849
Name:BERGERON, BREANNA K (RD)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:K
Last Name:BERGERON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:
Practice Address - Street 1:212 E CENTRAL AVE
Practice Address - Street 2:STE. 440
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-6291
Practice Address - Country:US
Practice Address - Phone:509-252-9602
Practice Address - Fax:509-227-7070
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK175133V00000X
IDD-530133V00000X
WADI60595970133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDT9813Medicaid
AK8EC297Medicare ID - Type Unspecified