Provider Demographics
NPI:1467753707
Name:BERRY, REBECCA L (ACNP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:BERRY
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:L
Other - Last Name:RODGERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ACNP
Mailing Address - Street 1:2205 E. 70TH STREET
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-3813
Mailing Address - Country:US
Mailing Address - Phone:318-797-1585
Mailing Address - Fax:318-797-6077
Practice Address - Street 1:2205 E 70TH ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5321
Practice Address - Country:US
Practice Address - Phone:318-797-1585
Practice Address - Fax:318-797-6077
Is Sole Proprietor?:No
Enumeration Date:2010-11-03
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06053363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2129678Medicaid
LA381005YJBAMedicare PIN