Provider Demographics
NPI:1649381245
Name:BERRY, SHANNON (CNM)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BREWSTER BLVD
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28547-2538
Mailing Address - Country:US
Mailing Address - Phone:910-450-4136
Mailing Address - Fax:910-450-4558
Practice Address - Street 1:100 BREWSTER BLVD
Practice Address - Street 2:MEDICAL STAFF SERVICES
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-2538
Practice Address - Country:US
Practice Address - Phone:910-450-4136
Practice Address - Fax:910-450-4558
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-005332367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife