Provider Demographics
NPI:1053689505
Name:BERRY, EDWINA LYNETTE (FNP)
Entity Type:Individual
Prefix:
First Name:EDWINA
Middle Name:LYNETTE
Last Name:BERRY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1005
Mailing Address - Country:US
Mailing Address - Phone:336-544-5400
Mailing Address - Fax:336-544-5401
Practice Address - Street 1:1309 N ELM ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1005
Practice Address - Country:US
Practice Address - Phone:336-544-5400
Practice Address - Fax:336-544-5401
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5005447363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health