Provider Demographics
NPI:1659492361
Name:BERRY, MARIAN ADALE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:ADALE
Last Name:BERRY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:MARIAN
Other - Middle Name:BAGGETT
Other - Last Name:MENKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:643 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:GA
Mailing Address - Zip Code:30268-1138
Mailing Address - Country:US
Mailing Address - Phone:404-929-8824
Mailing Address - Fax:404-929-9769
Practice Address - Street 1:202 CROFT ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3803
Practice Address - Country:US
Practice Address - Phone:770-834-2255
Practice Address - Fax:770-834-7100
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN158389363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA309752602CMedicaid