Provider Demographics
NPI:1457131583
Name:BERGH, PHYLLIS (RN)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:BERGH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:
Other - Last Name:LATVALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:900 W SHARON AVE
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:49931-1920
Mailing Address - Country:US
Mailing Address - Phone:906-482-9404
Mailing Address - Fax:906-487-7713
Practice Address - Street 1:900 W SHARON AVE
Practice Address - Street 2:
Practice Address - City:HOUGHTON
Practice Address - State:MI
Practice Address - Zip Code:49931-1920
Practice Address - Country:US
Practice Address - Phone:906-482-9404
Practice Address - Fax:906-487-7713
Is Sole Proprietor?:No
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704267328163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health