Healthcare Provider Details

I. General information

NPI: 1952414898
Provider Name (Legal Business Name): DIANE BERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1344 S APOLLO BLVD STE #301
MELBOURNE FL
32901-3183
US

IV. Provider business mailing address

1344 S APOLLO BLVD STE #301
MELBOURNE FL
32901-3183
US

V. Phone/Fax

Practice location:
  • Phone: 321-676-2353
  • Fax: 321-951-9267
Mailing address:
  • Phone: 321-676-2353
  • Fax: 321-951-9267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberARNP 2722652
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: