Provider Demographics
NPI:1164473591
Name:BERRY, MARIE A (APNP)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:A
Last Name:BERRY
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 S UNIVERSITY AVE
Mailing Address - Street 2:STE 510
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-3081
Mailing Address - Country:US
Mailing Address - Phone:920-887-3102
Mailing Address - Fax:920-885-8788
Practice Address - Street 1:705 S UNIVERSITY AVE
Practice Address - Street 2:STE 510
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3081
Practice Address - Country:US
Practice Address - Phone:920-887-3102
Practice Address - Fax:920-885-8788
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI67440-030163WD0400X
WI8-033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4288OtherDEAN HEALTH INSURANCE
WI2006175OtherPHYSICIANS PLUS
WI43823400Medicaid
WI009554375Medicare PIN
WI4288OtherDEAN HEALTH INSURANCE
WI080179052Medicare PIN