Provider Demographics
NPI:1790213791
Name:BERRY, KITTY (RN)
Entity Type:Individual
Prefix:
First Name:KITTY
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KITTY
Other - Middle Name:RAY
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 696
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-0030
Mailing Address - Country:US
Mailing Address - Phone:541-729-7277
Mailing Address - Fax:
Practice Address - Street 1:31161 KENADY LN
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-9721
Practice Address - Country:US
Practice Address - Phone:541-729-7277
Practice Address - Fax:541-729-7277
Is Sole Proprietor?:No
Enumeration Date:2017-06-02
Last Update Date:2017-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200843078RN101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR200843078RNOtherSTATE OF OREGON BOARD OF NURSING