Provider Demographics
NPI:1194512467
Name:BERGOLLA, JOHANNYS
Entity type:Individual
Prefix:
First Name:JOHANNYS
Middle Name:
Last Name:BERGOLLA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1381 W 30TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-4853
Mailing Address - Country:US
Mailing Address - Phone:305-989-5518
Mailing Address - Fax:
Practice Address - Street 1:1381 W 30TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-4853
Practice Address - Country:US
Practice Address - Phone:305-989-5518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-21
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11038862363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health