MEDICARE: DR. BERNETTA LYNNE AVERY M.D.

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	208000000X	Pediatrics Physician	MD 60265069	WA
2	208000000X	Pediatrics Physician	MD150622	OR
3	208000000X	Pediatrics Physician	A91477	CA
4	208000000X	Pediatrics Physician	301639-01	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1740391630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BERNETTA LYNNE AVERY M.D.

Provider Business Mailing Address
First Line	:	700 NE 87TH AVE
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98664-1913
Country	:	US
Telephone Number	:	360-397-3352
Fax Number	:	360-604-1771

Provider Business Practice Location Address
First Line	:	209 YORK ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11201-1509
Country	:	US
Telephone Number	:	718-630-7942
Fax Number	:	718-630-7000

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	08/06/2021

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