Provider Demographics
NPI:1033196134
Name:BERRY, MARY (NP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11803 JEFFERSON AVE STE 235
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-2565
Mailing Address - Country:US
Mailing Address - Phone:757-594-1806
Mailing Address - Fax:757-510-9079
Practice Address - Street 1:11803 JEFFERSON AVE STE 235
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-2565
Practice Address - Country:US
Practice Address - Phone:757-594-1806
Practice Address - Fax:757-510-9079
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024164915363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA500026470OtherRAILROAD MEDICARE
VA7790660Medicaid
VAP41423Medicare UPIN
VA7790660Medicaid