Basic Information
| Provider Information | |||||||||
| NPI: | 1720420243 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERGERON | ||||||||
| FirstName: | KATHLYN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MS, RN | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BELLEFEUILLE | ||||||||
| OtherFirstName: | KATHLYN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1900 SILVER LAKE RD NW | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551121786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516289566 | ||||||||
| FaxNumber: | 6516280411 | ||||||||
| Practice Location | |||||||||
| Address1: | 1811 WEIR DR | ||||||||
| Address2: | SUITE 270 | ||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551252272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517149646 | ||||||||
| FaxNumber: | 9517149647 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2013 | ||||||||
| LastUpdateDate: | 01/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 2596 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.