Basic Information
| Provider Information | |||||||||
| NPI: | 1083669733 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERRY-PETTIT | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 941 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | PIKETON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456619757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402892371 | ||||||||
| FaxNumber: | 7402894291 | ||||||||
| Practice Location | |||||||||
| Address1: | 621 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456624788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7409614011 | ||||||||
| FaxNumber: | 7409614010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 04/25/2019 | ||||||||
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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 | 364SW0102X | NS01128 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 0151259 | 05 | OH | MEDICAID |