Healthcare Provider Details

I. General information

NPI: 1104495175
Provider Name (Legal Business Name): PRISCILLA BERRY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PRISCILLA MARIUSSO

II. Dates (important events)

Enumeration Date: 06/23/2021
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 E POST RD
WHITE PLAINS NY
10601-4607
US

IV. Provider business mailing address

560 W 168TH ST
NEW YORK NY
10032-3917
US

V. Phone/Fax

Practice location:
  • Phone: 914-681-0600
  • Fax:
Mailing address:
  • Phone: 212-305-4318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number632611
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number632611
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: