Provider Demographics
NPI:1740391630
Name:AVERY, BERNETTA LYNNE (MD)
Entity Type:Individual
Prefix:DR
First Name:BERNETTA
Middle Name:LYNNE
Last Name:AVERY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 NE 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-1913
Mailing Address - Country:US
Mailing Address - Phone:360-397-3352
Mailing Address - Fax:360-604-1771
Practice Address - Street 1:209 YORK ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-1509
Practice Address - Country:US
Practice Address - Phone:718-630-7942
Practice Address - Fax:718-630-7000
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD 60265069208000000X
ORMD150622208000000X
CAA91477208000000X
NY301639-01208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A914770Medicaid
CA00A914770Medicaid
CA00A914770Medicare PIN