Provider Demographics
NPI:1174851547
Name:BERRY, KATHLEEN M (FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:M
Last Name:BERRY
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:MS
Other - First Name:KATHLEEN
Other - Middle Name:M
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:5859 W TALAVI BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-1869
Mailing Address - Country:US
Mailing Address - Phone:602-298-7777
Mailing Address - Fax:623-930-6060
Practice Address - Street 1:5859 W TALAVI BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-1869
Practice Address - Country:US
Practice Address - Phone:602-298-7777
Practice Address - Fax:623-930-6060
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-24
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP-3489363LF0000X
AZRN137226163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse