Provider Demographics
NPI:1093066979
Name:BERRY, NATENA JO (COTA)
Entity Type:Individual
Prefix:MISS
First Name:NATENA
Middle Name:JO
Last Name:BERRY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 RAINTREE RD
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46582-7631
Mailing Address - Country:US
Mailing Address - Phone:574-527-4630
Mailing Address - Fax:
Practice Address - Street 1:1800 N WABASH RD
Practice Address - Street 2:SUITE 200
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-1300
Practice Address - Country:US
Practice Address - Phone:765-651-3229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-02
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN98000497A314000000X
IN244941314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility