Healthcare Provider Details

I. General information

NPI: 1154799625
Provider Name (Legal Business Name): REGINA BERRY CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: REGINA WILSON RN

II. Dates (important events)

Enumeration Date: 09/14/2015
Last Update Date: 09/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 E FORTIFICATION ST
JACKSON MS
39202-2442
US

IV. Provider business mailing address

1325 E FORTIFICATION ST
JACKSON MS
39202-2442
US

V. Phone/Fax

Practice location:
  • Phone: 601-354-4488
  • Fax: 601-914-1835
Mailing address:
  • Phone: 601-354-4488
  • Fax: 601-914-1835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR861126
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: