Healthcare Provider Details

I. General information

NPI: 1083669733
Provider Name (Legal Business Name): CAROLYN L BERRY-PETTIT CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 04/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 BROADWAY ST
PORTSMOUTH OH
45662-4788
US

IV. Provider business mailing address

941 MARKET ST
PIKETON OH
45661-9757
US

V. Phone/Fax

Practice location:
  • Phone: 740-961-4011
  • Fax: 740-961-4010
Mailing address:
  • Phone: 740-289-2371
  • Fax: 740-289-4291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SW0102X
TaxonomyWomen's Health Clinical Nurse Specialist
License NumberNS01128
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: