MEDICARE: MRS. CRYSTAL BERRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	RN205005	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	84-1481182	OTHER	GA	ALL INSURERS

General Provider Information

NPI Number	:	1013390350
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CRYSTAL BERRY

Provider Business Mailing Address
First Line	:	611 BROWN AVE
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31906-3627
Country	:	US
Telephone Number	:	678-729-7973
Fax Number	:

Provider Business Practice Location Address
First Line	:	611 BROWN AVE
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31906-3627
Country	:	US
Telephone Number	:	678-729-7973
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2015
Last Update Date	:	07/21/2022

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