MEDICARE: ANGELA RENEE BERRY ANP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	2015011469	MO
2	363L00000X	Nurse Practitioner	5015653	NC
3	363L00000X	Nurse Practitioner	25474	SC

General Provider Information

NPI Number	:	1174983878
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA RENEE BERRY ANP

Provider Business Mailing Address
First Line	:	PO BOX 740013
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-0013
Country	:	US
Telephone Number	:	312-733-9730
Fax Number	:	773-866-8014

Provider Business Practice Location Address
First Line	:	1735 HECKLE BLVD UNIT M-S130
Second Line	:
City	:	ROCK HILL
State	:	SC
Zip	:	29732-4803
Country	:	US
Telephone Number	:	803-659-3444
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/24/2016
Last Update Date	:	10/18/2024

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