Provider Demographics
NPI:1912272386
Name:BERGERON, KRISTINA KATHLEEN (LPN)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:KATHLEEN
Last Name:BERGERON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 BLACK CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-1945
Mailing Address - Country:US
Mailing Address - Phone:585-328-0196
Mailing Address - Fax:
Practice Address - Street 1:61 BLACK CREEK RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-1945
Practice Address - Country:US
Practice Address - Phone:585-328-0196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-18
Last Update Date:2012-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300124-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse