Provider Demographics
NPI:1760713481
Name:BERRY, BRANDIE DANIELLE (CRNA)
Entity Type:Individual
Prefix:MS
First Name:BRANDIE
Middle Name:DANIELLE
Last Name:BERRY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:BRANDIE
Other - Middle Name:
Other - Last Name:WIGGINTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:100 E LIBERTY ST STE 800
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1428
Mailing Address - Country:US
Mailing Address - Phone:502-361-6617
Mailing Address - Fax:502-361-6637
Practice Address - Street 1:1850 BLUEGRASS AVE
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-1161
Practice Address - Country:US
Practice Address - Phone:502-361-6617
Practice Address - Fax:502-361-6637
Is Sole Proprietor?:No
Enumeration Date:2010-01-20
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006323367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100109380Medicaid
IN200975010AMedicaid
KYK061002 (JPG)Medicare PIN
IN200975010AMedicaid