Provider Demographics
NPI:1578159273
Name:BERRY, EMILIE (RD)
Entity Type:Individual
Prefix:
First Name:EMILIE
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:494 HUB BLVD APT 121
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-8922
Mailing Address - Country:US
Mailing Address - Phone:502-523-6133
Mailing Address - Fax:
Practice Address - Street 1:494 HUB BLVD APT 121
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-8922
Practice Address - Country:US
Practice Address - Phone:502-523-6133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY171326133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered