Provider Demographics
NPI:1083669733
Name:BERRY-PETTIT, CAROLYN L (CNS)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:L
Last Name:BERRY-PETTIT
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:941 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:PIKETON
Mailing Address - State:OH
Mailing Address - Zip Code:45661-9757
Mailing Address - Country:US
Mailing Address - Phone:740-289-2371
Mailing Address - Fax:740-289-4291
Practice Address - Street 1:621 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-4788
Practice Address - Country:US
Practice Address - Phone:740-961-4011
Practice Address - Fax:740-961-4010
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNS01128364SW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SW0102XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0151259Medicaid