Healthcare Provider Details

I. General information

NPI: 1942702014
Provider Name (Legal Business Name): STACEY WARREN BERRY APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2018
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 NE 20TH AVE STE 120
PORTLAND OR
97232-2268
US

IV. Provider business mailing address

10824 SE OAK ST STE 314
MILWAUKIE OR
97222-6694
US

V. Phone/Fax

Practice location:
  • Phone: 971-337-3456
  • Fax: 866-324-6009
Mailing address:
  • Phone: 971-337-3456
  • Fax: 866-324-6009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number202007113NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: