Provider Demographics
NPI:1831636281
Name:BERGEN, LEONA M (ACNPC-AG)
Entity type:Individual
Prefix:
First Name:LEONA
Middle Name:M
Last Name:BERGEN
Suffix:
Gender:F
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:LEONA
Other - Middle Name:M
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2169 WAYNE 380
Mailing Address - Street 2:
Mailing Address - City:PATTERSON
Mailing Address - State:MO
Mailing Address - Zip Code:63956-7106
Mailing Address - Country:US
Mailing Address - Phone:573-944-0514
Mailing Address - Fax:
Practice Address - Street 1:3100 OAK GROVE RD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-1573
Practice Address - Country:US
Practice Address - Phone:573-776-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-24
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016037517363LG0600X
MO2019007962363LF0000X
282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily