Healthcare Provider Details

I. General information

NPI: 1316056427
Provider Name (Legal Business Name): ALLEN R BERRY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10180 SE SUNNYSIDE RD
CLACKAMAS OR
97015-8970
US

IV. Provider business mailing address

14810 NE 160TH AVE
BRUSH PRAIRIE WA
98606-4900
US

V. Phone/Fax

Practice location:
  • Phone: 503-652-2880
  • Fax:
Mailing address:
  • Phone: 360-882-8086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: