Basic Information
Provider Information | |||||||||
NPI: | 1174851547 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BERRY | ||||||||
FirstName: | KATHLEEN | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BERRY | ||||||||
OtherFirstName: | KATHLEEN | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | FNP-BC | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 5859 W TALAVI BLVD | ||||||||
Address2: | SUITE 100 | ||||||||
City: | GLENDALE | ||||||||
State: | AZ | ||||||||
PostalCode: | 853061869 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6022987777 | ||||||||
FaxNumber: | 6239306060 | ||||||||
Practice Location | |||||||||
Address1: | 5859 W TALAVI BLVD | ||||||||
Address2: | SUITE 100 | ||||||||
City: | GLENDALE | ||||||||
State: | AZ | ||||||||
PostalCode: | 853061869 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6022987777 | ||||||||
FaxNumber: | 6239306060 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/24/2009 | ||||||||
LastUpdateDate: | 05/13/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP-3489 | AZ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | RN137226 | AZ | N |   | Nursing Service Providers | Registered Nurse |   |
No ID Information.