Provider Demographics
NPI:1659321347
Name:BERHALTER, VICTORIA S (CRNA)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:S
Last Name:BERHALTER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 27TH AVE N APT B
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-3070
Mailing Address - Country:US
Mailing Address - Phone:843-444-4007
Mailing Address - Fax:
Practice Address - Street 1:71480 SHANNON DR
Practice Address - Street 2:
Practice Address - City:MARTINS FERRY
Practice Address - State:OH
Practice Address - Zip Code:43935-2333
Practice Address - Country:US
Practice Address - Phone:740-633-5211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC187249367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8051898Medicaid
NC8051898Medicaid