Provider Demographics
NPI:1710683784
Name:BERRY, ALEXANDRA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:MARIE
Last Name:BERRY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1678 JOSEPHINE RD
Mailing Address - Street 2:
Mailing Address - City:STAMPING GROUND
Mailing Address - State:KY
Mailing Address - Zip Code:40379-9641
Mailing Address - Country:US
Mailing Address - Phone:502-370-5991
Mailing Address - Fax:
Practice Address - Street 1:148 SKYVIEW DR
Practice Address - Street 2:
Practice Address - City:MT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-1496
Practice Address - Country:US
Practice Address - Phone:859-499-0717
Practice Address - Fax:859-499-0926
Is Sole Proprietor?:No
Enumeration Date:2023-02-01
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1210962363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100958080Medicaid