Healthcare Provider Details

I. General information

NPI: 1740994268
Provider Name (Legal Business Name): DEZIRAE E BERRY NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2023
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1119 HIGHLAND AVE
CLARKSTON WA
99403-2836
US

IV. Provider business mailing address

1522 17TH ST
LEWISTON ID
83501-3652
US

V. Phone/Fax

Practice location:
  • Phone: 509-769-2269
  • Fax: 509-769-2270
Mailing address:
  • Phone: 208-743-8416
  • Fax: 208-743-4642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number55464
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberN361446320
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number55464
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: