Basic Information
| Provider Information | |||||||||
| NPI: | 1740598077 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERGERON | ||||||||
| FirstName: | EBONEE | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4132 MEDOC DR | ||||||||
| Address2: | |||||||||
| City: | KENNER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700651923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5049058647 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4055 VALLEY VIEW LN STE 400 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752445071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727153800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2010 | ||||||||
| LastUpdateDate: | 08/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP10181 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.