Basic Information
| Provider Information | |||||||||
| NPI: | 1083042162 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAN BERRY | ||||||||
| FirstName: | ELSA PETRONELLA | ||||||||
| MiddleName: | |||||||||
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| Credential: | CRYT, RN, MSN,FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3687 MT DIABLO BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945493746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102046660 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3100 SUMMIT ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946093412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108698865 | ||||||||
| FaxNumber: | 5108696271 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2013 | ||||||||
| LastUpdateDate: | 12/12/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 2011003399 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 55-1876 | 01 | CA | MEDICARE PROVIDER # | OTHER |