MEDICARE: MRS. JENNY REPLOGLE BERRY APN

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	363LA2200X	Adult Health Nurse Practitioner	2012004406	MO
2	363L00000X	Nurse Practitioner	1953	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	880N26	OTHER	TX	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912261140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNY REPLOGLE BERRY APN

Provider Business Mailing Address
First Line	:	PO BOX 4439
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77210-4439
Country	:	US
Telephone Number	:	713-792-2991
Fax Number	:

Provider Business Practice Location Address
First Line	:	1515 HOLCOMBE BLVD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-2009
Country	:	US
Telephone Number	:	713-792-6161
Fax Number	:

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

Provider Enumeration Date	:	07/03/2012
Last Update Date	:	01/17/2013

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