Provider Demographics
NPI:1982614491
Name:BERG, NANCY MANSUETO (APRN)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:MANSUETO
Last Name:BERG
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 MANSFIELD RD
Mailing Address - Street 2:
Mailing Address - City:FAYSTON
Mailing Address - State:VT
Mailing Address - Zip Code:05673-7406
Mailing Address - Country:US
Mailing Address - Phone:802-496-4375
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:352 MP4
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101-0019495363LA2200X, 363LP2300X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0NP0830Medicaid
VTBENP0830Medicare ID - Type Unspecified
VT0NP0830Medicaid