Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 95019889 | CA |
N | 363LC0200X | Nurse Practitioner - Critical Care Medicine | 95019889 | CA |
NPI | 1508446089 |
---|---|
Provider Name | Skye Raelynn Porter Berg |
First Address | Galt, CA 95632-2377 |
Second Address | Sacramento, CA 95816-6039 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/04/2021 |
Last Update Date | 03/02/2022 |