Basic Information
| Provider Information | |||||||||
| NPI: | 1508446089 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTER BERG | ||||||||
| FirstName: | SKYE | ||||||||
| MiddleName: | RAELYNN | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29 SUNSHINE CT | ||||||||
| Address2: | |||||||||
| City: | GALT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956322377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803896361 | ||||||||
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| Practice Location | |||||||||
| Address1: | 901 MCCLINTOCK DR STE 202 | ||||||||
| Address2: | |||||||||
| City: | BURR RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605270872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305902830 | ||||||||
| FaxNumber: | 6307344715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2021 | ||||||||
| LastUpdateDate: | 03/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WE0003X | 95223197 | CA | N | Nursing Service Providers | Registered Nurse | Emergency | 207RI0011X | 95019889 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 363L00000X | 95019889 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LC0200X | 95019889 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00000 | 05 | IL | MEDICAID |