Provider Demographics
NPI:1487420048
Name:BERGSTROM, MARY KATHLEEN (RDN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KATHLEEN
Other - Last Name:ROBBINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN
Mailing Address - Street 1:15865 AVENIDA VENUSTO APT 816
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-3396
Mailing Address - Country:US
Mailing Address - Phone:662-231-0163
Mailing Address - Fax:
Practice Address - Street 1:15865 AVENIDA VENUSTO APT 816
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-3396
Practice Address - Country:US
Practice Address - Phone:662-231-0163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered