Provider Demographics
NPI:1326704602
Name:BERRY, TINISHIA NICOLE (LPN)
Entity Type:Individual
Prefix:
First Name:TINISHIA
Middle Name:NICOLE
Last Name:BERRY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2627 CORNER CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-4381
Mailing Address - Country:US
Mailing Address - Phone:850-797-3775
Mailing Address - Fax:
Practice Address - Street 1:1200 E JAMES LEE BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-3126
Practice Address - Country:US
Practice Address - Phone:850-689-5690
Practice Address - Fax:850-689-5696
Is Sole Proprietor?:No
Enumeration Date:2021-11-11
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5208967164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse