Healthcare Provider Details

I. General information

NPI: 1558805184
Provider Name (Legal Business Name): MARLENE E BERLT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2016
Last Update Date: 12/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

#1054 RT. 23B
LEEDS NY
12451
US

IV. Provider business mailing address

PO BOX 412
LEEDS NY
12451-0412
US

V. Phone/Fax

Practice location:
  • Phone: 518-965-2580
  • Fax:
Mailing address:
  • Phone: 518-965-2580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number556943-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: