Provider Demographics
NPI:1255353843
Name:BERG, KIMBERLY LYNN (NP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LYNN
Last Name:BERG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:225 SMITH AVE N STE 201
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-2697
Mailing Address - Country:US
Mailing Address - Phone:651-241-5290
Mailing Address - Fax:651-241-5248
Practice Address - Street 1:225 SMITH AVE N STE 201
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2697
Practice Address - Country:US
Practice Address - Phone:651-241-5290
Practice Address - Fax:651-241-5248
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNR 123060-4363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
P88647Medicare UPIN