Provider Demographics
NPI:1629564315
Name:BERRY, CODIE (RN)
Entity Type:Individual
Prefix:
First Name:CODIE
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 BLOUNTVILLE BYP
Mailing Address - Street 2:
Mailing Address - City:BLOUNTVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37617-4575
Mailing Address - Country:US
Mailing Address - Phone:423-279-7597
Mailing Address - Fax:
Practice Address - Street 1:154 BLOUNTVILLE BYP
Practice Address - Street 2:
Practice Address - City:BLOUNTVILLE
Practice Address - State:TN
Practice Address - Zip Code:37617-4575
Practice Address - Country:US
Practice Address - Phone:423-279-7597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-05
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC278196163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3170197Medicaid