Provider Demographics
NPI:1861857963
Name:BERRY, NADRA (LVN)
Entity Type:Individual
Prefix:
First Name:NADRA
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9706 SVL BOX
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5177
Mailing Address - Country:US
Mailing Address - Phone:760-596-4031
Mailing Address - Fax:
Practice Address - Street 1:13070 BERMUDA DUNES RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5177
Practice Address - Country:US
Practice Address - Phone:760-596-4031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-16
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA267872164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse