Provider Demographics
NPI:1104533439
Name:BERG, EVELYN (RN)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:BERG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:EVELYN
Other - Middle Name:
Other - Last Name:ESPINOSA DOMINGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3380 E OAKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-6031
Mailing Address - Country:US
Mailing Address - Phone:414-739-7602
Mailing Address - Fax:
Practice Address - Street 1:3380 E OAKWOOD RD
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-6031
Practice Address - Country:US
Practice Address - Phone:414-739-7602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI259021163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse