Provider Demographics
NPI:1558619981
Name:BERRY, MELISSA (RD, LN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:RD, LN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 CANYON LAKE DR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-8114
Mailing Address - Country:US
Mailing Address - Phone:605-355-2493
Mailing Address - Fax:
Practice Address - Street 1:3200 CANYON LAKE DR
Practice Address - Street 2:IHS, SIOUX SAN HOSPITAL,
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-8114
Practice Address - Country:US
Practice Address - Phone:605-355-2493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0390133V00000X
1018199133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered