Provider Demographics
NPI:1912368234
Name:BERRY, MIKE DOUGLAS (FNP)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:DOUGLAS
Last Name:BERRY
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 S 336TH ST STE 350
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-5948
Mailing Address - Country:US
Mailing Address - Phone:253-733-3969
Mailing Address - Fax:
Practice Address - Street 1:888 SWIFT BLVD
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3514
Practice Address - Country:US
Practice Address - Phone:509-946-4611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60610441363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner