Provider Demographics
NPI:1114165073
Name:BERRY, ELVIA ANGELICA (ANP)
Entity Type:Individual
Prefix:
First Name:ELVIA
Middle Name:ANGELICA
Last Name:BERRY
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2445 W SILVER SAGE LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-5740
Mailing Address - Country:US
Mailing Address - Phone:623-977-9657
Mailing Address - Fax:623-583-7432
Practice Address - Street 1:6818 W THUNDERBIRD RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5025
Practice Address - Country:US
Practice Address - Phone:623-566-3550
Practice Address - Fax:623-566-3573
Is Sole Proprietor?:No
Enumeration Date:2009-01-30
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN098573163W00000X
AZAP3187363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ409313Medicaid
AZ409313Medicaid