Healthcare Provider Details

I. General information

NPI: 1164783502
Provider Name (Legal Business Name): JOANNA LEE BERRY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2012
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E BRUNSON ST STE 200
ENTERPRISE AL
36330-2500
US

IV. Provider business mailing address

101 E BRUNSON ST STE 200
ENTERPRISE AL
36330-2500
US

V. Phone/Fax

Practice location:
  • Phone: 334-393-3686
  • Fax: 334-347-4096
Mailing address:
  • Phone: 334-347-0584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-105643
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: