Provider Demographics
NPI:1508136870
Name:BERRY, NICHOLAS SCOTT (CRNA)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:SCOTT
Last Name:BERRY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2369 HACKBERRY LN
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA
Mailing Address - State:AL
Mailing Address - Zip Code:35226-3037
Mailing Address - Country:US
Mailing Address - Phone:205-470-4930
Mailing Address - Fax:
Practice Address - Street 1:619 19TH ST S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35249-1900
Practice Address - Country:US
Practice Address - Phone:205-934-6948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-111754367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered