Provider Demographics
NPI:1740994268
Name:BERRY, DEZIRAE E (NP-C)
Entity type:Individual
Prefix:
First Name:DEZIRAE
Middle Name:E
Last Name:BERRY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1522 17TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-3652
Mailing Address - Country:US
Mailing Address - Phone:208-743-8416
Mailing Address - Fax:208-743-4642
Practice Address - Street 1:1522 17TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-3652
Practice Address - Country:US
Practice Address - Phone:208-743-8416
Practice Address - Fax:208-743-4642
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID55464163W00000X, 363LF0000X
WAN361446320363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse