Provider Demographics
NPI:1912016197
Name:BERRY, DEBRA (NP)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 MOUNT HOPE AVE
Mailing Address - Street 2:SUITE 116
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-3917
Mailing Address - Country:US
Mailing Address - Phone:585-275-8503
Mailing Address - Fax:585-276-2249
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:BOX278984
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-0001
Practice Address - Country:US
Practice Address - Phone:585-275-8503
Practice Address - Fax:585-276-2249
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY301310363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11145AMedicare PIN
NYP16545Medicare UPIN