Provider Demographics
NPI:1265951255
Name:BERRY, KAILEN (ATC)
Entity type:Individual
Prefix:
First Name:KAILEN
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28190 CREST PRESERVE CIR UNIT 6109
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-6765
Mailing Address - Country:US
Mailing Address - Phone:260-908-4486
Mailing Address - Fax:
Practice Address - Street 1:5050 AVE MARIA BLVD
Practice Address - Street 2:
Practice Address - City:AVE MARIA
Practice Address - State:FL
Practice Address - Zip Code:34142-9505
Practice Address - Country:US
Practice Address - Phone:239-304-7865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-12
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program