Provider Demographics
NPI:1235759168
Name:BERGH, LISA DIANA
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:DIANA
Last Name:BERGH
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:DIANA
Other - Last Name:LOPRESTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18382 FERN RD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33967-3242
Mailing Address - Country:US
Mailing Address - Phone:239-250-0007
Mailing Address - Fax:
Practice Address - Street 1:9981 S HEALTHPARK DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3620
Practice Address - Country:US
Practice Address - Phone:239-343-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9336837367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered