Basic Information
| Provider Information | |||||||||
| NPI: | 1154799625 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERRY | ||||||||
| FirstName: | REGINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILSON | ||||||||
| OtherFirstName: | REGINA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1325 E FORTIFICATION ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013544488 | ||||||||
| FaxNumber: | 6019141835 | ||||||||
| Practice Location | |||||||||
| Address1: | 1325 E FORTIFICATION ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013544488 | ||||||||
| FaxNumber: | 6019141835 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2015 | ||||||||
| LastUpdateDate: | 09/14/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | R861126 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.