Provider Demographics
NPI:1770914657
Name:MCDONALD, BERTHA
Entity type:Individual
Prefix:
First Name:BERTHA
Middle Name:
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:BERTHA
Other - Middle Name:COVIN
Other - Last Name:MCDONALD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:1120 W BROAD AVE
Mailing Address - Street 2:C-3
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-4397
Mailing Address - Country:US
Mailing Address - Phone:229-430-4138
Mailing Address - Fax:229-430-4422
Practice Address - Street 1:1120 W BROAD AVE
Practice Address - Street 2:C-3
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-4397
Practice Address - Country:US
Practice Address - Phone:229-430-4138
Practice Address - Fax:229-430-4422
Is Sole Proprietor?:No
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN052615163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse