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General NPI Number Information
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NPI Number | 1639520364
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Entity Type | Individual
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Provider Name | WAKIYA CHANEL BERRY AGNP-C
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Gender | Female
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Dates
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Enumeration Date | 06/23/2016
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Last Update Date | 02/03/2026
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Provider Practice Location Address
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Address Line | 1875 REMOUNT RD
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City | GASTONIA
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State | NC
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Zip | 28054-7413
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Country | US
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Telephone | 704-874-0600
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Fax |
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Provider Business Mailing Address
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Address Line | 200 E 2ND AVE
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City | GASTONIA
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State | NC
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Zip | 28052-4358
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Country | US
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Telephone | 704-874-1900
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 27183
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 5008660
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License Number State | NC
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