Provider Demographics
NPI:1356836332
Name:BERRY, MALORY (NP)
Entity Type:Individual
Prefix:
First Name:MALORY
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 655
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:TN
Mailing Address - Zip Code:38372-0655
Mailing Address - Country:US
Mailing Address - Phone:731-925-2300
Mailing Address - Fax:
Practice Address - Street 1:765 FLORENCE RD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:TN
Practice Address - Zip Code:38372
Practice Address - Country:US
Practice Address - Phone:731-925-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-22
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24631363LP0808X
TN185481163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse