Provider Demographics
NPI:1720853666
Name:BERBERICH, KELSEY (AGACNP)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:BERBERICH
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-3800
Mailing Address - Fax:239-343-3993
Practice Address - Street 1:2780 CLEVELAND AVE STE 811
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-5817
Practice Address - Country:US
Practice Address - Phone:239-343-3800
Practice Address - Fax:239-343-3993
Is Sole Proprietor?:No
Enumeration Date:2023-11-21
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11030613363LA2200X
FLRN9446083163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL121031900Medicaid