Provider Demographics
NPI:1336352939
Name:BERG, MARY EILEEN (NP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:EILEEN
Last Name:BERG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:536 E MARIPOSA ST
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784-2071
Mailing Address - Country:US
Mailing Address - Phone:909-931-1033
Mailing Address - Fax:909-981-8976
Practice Address - Street 1:600 N MOUNTAIN AVE
Practice Address - Street 2:SUITE A104
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4359
Practice Address - Country:US
Practice Address - Phone:909-931-1033
Practice Address - Fax:909-981-8976
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA389253363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology