Provider Demographics
NPI:1083397327
Name:A BERRY, TELISHA A
Entity Type:Individual
Prefix:
First Name:TELISHA
Middle Name:A
Last Name:A BERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6619 EAGLES NEST LN
Mailing Address - Street 2:
Mailing Address - City:MCCORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46055-0050
Mailing Address - Country:US
Mailing Address - Phone:317-496-1540
Mailing Address - Fax:
Practice Address - Street 1:6619 EAGLES NEST LN
Practice Address - Street 2:
Practice Address - City:MCCORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46055-0050
Practice Address - Country:US
Practice Address - Phone:317-496-1540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-11
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
23-0157163747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider