Healthcare Provider Details

I. General information

NPI: 1164473591
Provider Name (Legal Business Name): MARIE A BERRY APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 05/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 S UNIVERSITY AVE STE 510
BEAVER DAM WI
53916-3081
US

IV. Provider business mailing address

705 S UNIVERSITY AVE STE 510
BEAVER DAM WI
53916-3081
US

V. Phone/Fax

Practice location:
  • Phone: 920-887-3102
  • Fax: 920-885-8788
Mailing address:
  • Phone: 920-887-3102
  • Fax: 920-885-8788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number8-033
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number67440-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: