MEDICARE: KELLEY BERBERICH RN FNP-C

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	363LF0000X	Family Nurse Practitioner	16721	CA

General Provider Information

NPI Number	:	1285758151
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLEY BERBERICH RN FNP-C

Provider Business Mailing Address
First Line	:	1216 SUNCAST LN
Second Line	:	SUITE 1
City	:	EL DORADO HILLS
State	:	CA
Zip	:	95762-9668
Country	:	US
Telephone Number	:	916-933-5028
Fax Number	:	915-933-8747

Provider Business Practice Location Address
First Line	:	1216 SUNCAST LN
Second Line	:	SUITE 1
City	:	EL DORADO HILLS
State	:	CA
Zip	:	95762-9668
Country	:	US
Telephone Number	:	916-933-5028
Fax Number	:	916-933-8747

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

Provider Enumeration Date	:	03/18/2007
Last Update Date	:	01/05/2011

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