Healthcare Provider Details

I. General information

NPI: 1962332296
Provider Name (Legal Business Name): WALTER THOMAS BERRY RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 SW 38TH ST
LAWTON OK
73505-6912
US

IV. Provider business mailing address

602 SW 38TH ST
LAWTON OK
73505-6912
US

V. Phone/Fax

Practice location:
  • Phone: 580-248-5780
  • Fax: 580-248-5780
Mailing address:
  • Phone: 580-248-5780
  • Fax: 580-248-5780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number227896
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: