Provider Demographics
NPI:1568940005
Name:BERRY, MELISSA ANN
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:BERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 LONG RD
Mailing Address - Street 2:
Mailing Address - City:POLLOCK
Mailing Address - State:LA
Mailing Address - Zip Code:71467-3032
Mailing Address - Country:US
Mailing Address - Phone:318-955-3035
Mailing Address - Fax:
Practice Address - Street 1:155 LONG RD
Practice Address - Street 2:
Practice Address - City:POLLOCK
Practice Address - State:LA
Practice Address - Zip Code:71467-3032
Practice Address - Country:US
Practice Address - Phone:318-955-3035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-06
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA008618951172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA83-1234218Medicaid