Provider Demographics
NPI:1730727108
Name:BERGUM, AVNI (NP)
Entity type:Individual
Prefix:
First Name:AVNI
Middle Name:
Last Name:BERGUM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109 HAMILTON RD STE 217
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-1700
Mailing Address - Country:US
Mailing Address - Phone:517-580-0575
Mailing Address - Fax:517-917-0826
Practice Address - Street 1:2109 HAMILTON RD STE 217
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-1700
Practice Address - Country:US
Practice Address - Phone:517-580-0575
Practice Address - Fax:517-917-0826
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704293729363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner