Provider Demographics
NPI:1659374130
Name:BERRY, ERICCA S (ARNP, CPNP)
Entity Type:Individual
Prefix:MS
First Name:ERICCA
Middle Name:S
Last Name:BERRY
Suffix:
Gender:F
Credentials:ARNP, CPNP
Other - Prefix:MS
Other - First Name:ERICCA
Other - Middle Name:S
Other - Last Name:CORNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:107 DILWORTH ST
Mailing Address - Street 2:
Mailing Address - City:GLENDIVE
Mailing Address - State:MT
Mailing Address - Zip Code:59330-2053
Mailing Address - Country:US
Mailing Address - Phone:406-345-8901
Mailing Address - Fax:
Practice Address - Street 1:107 DILWORTH ST
Practice Address - Street 2:
Practice Address - City:GLENDIVE
Practice Address - State:MT
Practice Address - Zip Code:59330-2053
Practice Address - Country:US
Practice Address - Phone:406-345-8901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS45442363LP0200X
TX751749363LP0200X
MT104569363LP0200X
MO2007020392363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8K5202OtherMEDICARE