Provider Demographics
NPI:1003354010
Name:BERRY, NICAEA (CCMA)
Entity Type:Individual
Prefix:
First Name:NICAEA
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:CCMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:349A E AVENUE K6
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-4548
Mailing Address - Country:US
Mailing Address - Phone:661-723-4260
Mailing Address - Fax:
Practice Address - Street 1:349A E AVENUE K6
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93535-4548
Practice Address - Country:US
Practice Address - Phone:661-723-4260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16114-16172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker