Provider Demographics
NPI:1306023528
Name:BERRY, KEELY ERIN (CRNP)
Entity Type:Individual
Prefix:
First Name:KEELY
Middle Name:ERIN
Last Name:BERRY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:KEELY
Other - Middle Name:ERIN
Other - Last Name:EAGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1620 OAK PARK LN
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:AL
Mailing Address - Zip Code:35080-7753
Mailing Address - Country:US
Mailing Address - Phone:205-939-9175
Mailing Address - Fax:205-558-2061
Practice Address - Street 1:1600 7TH AVE S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1711
Practice Address - Country:US
Practice Address - Phone:205-939-9175
Practice Address - Fax:205-558-2061
Is Sole Proprietor?:No
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1089150363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1089150Medicaid