1124420716 NPI number — MRS. KERRY ELLIS-BERRY A.R.N.P

Table of content: MRS. KERRY ELLIS-BERRY A.R.N.P (NPI 1124420716)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124420716 NPI number — MRS. KERRY ELLIS-BERRY A.R.N.P

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIS-BERRY
Provider First Name:
KERRY
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
A.R.N.P
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ELLIS
Provider Other First Name:
KERRY
Provider Other Middle Name:
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124420716
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14271 METROPOLIS AVE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33912
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-939-7777
Provider Business Mailing Address Fax Number:
239-936-0036

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14271 METROPOLIS AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33912
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-939-7777
Provider Business Practice Location Address Fax Number:
239-936-0036
Provider Enumeration Date:
09/25/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  ARNP2923672 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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