Healthcare Provider Details

I. General information

NPI: 1538509641
Provider Name (Legal Business Name): BRENDA BERRY NP FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2013
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 FAIRMONT BLVD
RAPID CITY SD
57701-7375
US

IV. Provider business mailing address

PO BOX 912882
DENVER CO
80291-2882
US

V. Phone/Fax

Practice location:
  • Phone: 605-755-8222
  • Fax: 605-719-4203
Mailing address:
  • Phone: 866-765-0909
  • Fax: 855-856-8520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCP000796
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP000796
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: