MEDICARE: LAKEITHA LANAY BERRY NP

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	363LP2300X	Primary Care Nurse Practitioner	0024174876	VA
2	363LG0600X	Gerontology Nurse Practitioner	1128046	TX
3	363LA2200X	Adult Health Nurse Practitioner	0024174876	VA
4	363LG0600X	Gerontology Nurse Practitioner	0024174876	VA

General Provider Information

NPI Number	:	1922537547
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAKEITHA LANAY BERRY NP

Provider Business Mailing Address
First Line	:	13523 PAXTON BLVD
Second Line	:
City	:	SAINT HEDWIG
State	:	TX
Zip	:	78152-0497
Country	:	US
Telephone Number	:	785-210-5152
Fax Number	:

Provider Business Practice Location Address
First Line	:	3030 ROOSEVELT AVE
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78214-2337
Country	:	US
Telephone Number	:	210-924-8151
Fax Number	:	210-783-9688

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

Provider Enumeration Date	:	06/07/2017
Last Update Date	:	03/09/2026

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