Provider Demographics
NPI:1447730916
Name:BERGESON, VICTORIA A (APRN)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:A
Last Name:BERGESON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 MAIN ST STE 202
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-3654
Mailing Address - Country:US
Mailing Address - Phone:860-912-8444
Mailing Address - Fax:
Practice Address - Street 1:11 MAIN ST STE 202
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-3654
Practice Address - Country:US
Practice Address - Phone:860-912-8444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT7765363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program