Healthcare Provider Details

I. General information

NPI: 1609396811
Provider Name (Legal Business Name): MS. EMILY BERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 06/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4575 SE DIXIE HWY
STUART FL
34997-6826
US

IV. Provider business mailing address

1508 SE ROYAL GREEN CIR APT E101
PORT SAINT LUCIE FL
34952-7629
US

V. Phone/Fax

Practice location:
  • Phone: 855-832-6727
  • Fax:
Mailing address:
  • Phone: 772-577-9644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: