Provider Demographics
NPI:1255088480
Name:BERRY, KELAIJA C (LPN)
Entity type:Individual
Prefix:
First Name:KELAIJA
Middle Name:C
Last Name:BERRY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1855 PANNELL AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-1655
Mailing Address - Country:US
Mailing Address - Phone:614-600-0773
Mailing Address - Fax:
Practice Address - Street 1:5665 HOOVER RD
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-9122
Practice Address - Country:US
Practice Address - Phone:614-539-6551
Practice Address - Fax:614-384-8094
Is Sole Proprietor?:No
Enumeration Date:2022-03-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH173585164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse