Healthcare Provider Details

I. General information

NPI: 1699080689
Provider Name (Legal Business Name): MICHELLE BERRY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2010
Last Update Date: 08/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3219 CENTRAL AVE
KEARNEY NE
68847-2949
US

IV. Provider business mailing address

3219 CENTRAL AVE
KEARNEY NE
68847-2949
US

V. Phone/Fax

Practice location:
  • Phone: 308-865-2263
  • Fax: 308-865-2541
Mailing address:
  • Phone: 308-865-2263
  • Fax: 308-865-2541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number2011-0243
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: