Provider Demographics
NPI:1700360492
Name:BERG, NICOLE ELIZABETH (CNP)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:BERG
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ELIZABETH
Other - Last Name:GAPP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:280 SMITH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-2424
Mailing Address - Country:US
Mailing Address - Phone:651-241-5958
Mailing Address - Fax:
Practice Address - Street 1:3033 EXCELSIOR BLVD STE 465
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-3372
Practice Address - Country:US
Practice Address - Phone:612-547-9990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-19
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6156363LP0808X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty