Provider Demographics
NPI:1710601786
Name:BERRY, KENNETH EDWARD
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:EDWARD
Last Name:BERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12722 SE 312TH ST APT H204
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98092-3149
Mailing Address - Country:US
Mailing Address - Phone:425-525-8871
Mailing Address - Fax:
Practice Address - Street 1:12722 SE 312TH ST APT H204
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98092-3149
Practice Address - Country:US
Practice Address - Phone:425-525-8871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-03
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No253Z00000XAgenciesIn Home Supportive Care