Healthcare Provider Details

I. General information

NPI: 1558288795
Provider Name (Legal Business Name): NICKALETT L BERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11011 Q ST STE 101C
OMAHA NE
68137-3700
US

IV. Provider business mailing address

712 ORLEANS DR APT 2
GRAND ISLAND NE
68803-3414
US

V. Phone/Fax

Practice location:
  • Phone: 402-697-5122
  • Fax:
Mailing address:
  • Phone: 308-379-3188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: