Provider Demographics
NPI:1366827156
Name:ATI, BERTY (LPN)
Entity Type:Individual
Prefix:MRS
First Name:BERTY
Middle Name:
Last Name:ATI
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:571 CHAPMAN ST
Mailing Address - Street 2:
Mailing Address - City:HILLSIDE
Mailing Address - State:NJ
Mailing Address - Zip Code:07205-1722
Mailing Address - Country:US
Mailing Address - Phone:561-846-1369
Mailing Address - Fax:
Practice Address - Street 1:571 CHAPMAN ST
Practice Address - Street 2:
Practice Address - City:HILLSIDE
Practice Address - State:NJ
Practice Address - Zip Code:07205-1722
Practice Address - Country:US
Practice Address - Phone:561-846-1369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-22
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY309205164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse