Provider Demographics
NPI:1730349242
Name:BERGGREN, KIMBERLY ANNE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANNE
Last Name:BERGGREN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANNE
Other - Last Name:NIELSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9TH MEDICAL GROUP
Mailing Address - Street 2:307 BOATNER RD, STE 114
Mailing Address - City:EGLIN AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32542-1282
Mailing Address - Country:US
Mailing Address - Phone:850-883-8132
Mailing Address - Fax:
Practice Address - Street 1:96TH MEDICAL GROUP
Practice Address - Street 2:307 BOATNER RD, SUITE 114
Practice Address - City:EGLIN AFB
Practice Address - State:FL
Practice Address - Zip Code:32542-1282
Practice Address - Country:US
Practice Address - Phone:508-838-1328
Practice Address - Fax:850-862-4423
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL363A00000X
CAPA20199363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ24117Medicare UPIN