Basic Information
| Provider Information | |||||||||
| NPI: | 1053511378 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERT | ||||||||
| FirstName: | KARLENE | ||||||||
| MiddleName: | HERTLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 576649 | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953576649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095718330 | ||||||||
| FaxNumber: | 2094917184 | ||||||||
| Practice Location | |||||||||
| Address1: | 1878 E HATCH RD | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953515002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2096028415 | ||||||||
| FaxNumber: | 2094917184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2007 | ||||||||
| LastUpdateDate: | 01/27/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 295673 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | MB660126B | 01 | CA | DEA | OTHER | 5419135 | 05 | CA | MEDICAID | 295673 NPF 4111 | 01 | LICENSE | OTHER |