=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710026257
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLIE L BERRY-HERT NURSE PRACTITIONER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2007
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3111 S 70TH ST
-----------------------------------------------------
City | FORT SMITH
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72903-5017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-452-6650
-----------------------------------------------------
Fax | 479-452-5847
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4201 S 36TH ST
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68107-1324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-917-3756
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | A004240
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------