Provider Demographics
NPI:1720420243
Name:BERGERON, KATHLYN (MS, RN)
Entity Type:Individual
Prefix:
First Name:KATHLYN
Middle Name:
Last Name:BERGERON
Suffix:
Gender:F
Credentials:MS, RN
Other - Prefix:
Other - First Name:KATHLYN
Other - Middle Name:
Other - Last Name:BELLEFEUILLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW
Mailing Address - Street 2:SUITE 110
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1786
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:651-628-0411
Practice Address - Street 1:1811 WEIR DR
Practice Address - Street 2:SUITE 270
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2272
Practice Address - Country:US
Practice Address - Phone:651-714-9646
Practice Address - Fax:951-714-9647
Is Sole Proprietor?:No
Enumeration Date:2013-07-25
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2596363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health