Basic Information
| Provider Information | |||||||||
| NPI: | 1144319971 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERRY | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 425 HOME ST | ||||||||
| Address2: | |||||||||
| City: | GEORGETOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451211407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137349050 | ||||||||
| FaxNumber: | 5137349051 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 N UNION ST | ||||||||
| Address2: | |||||||||
| City: | BETHEL | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451061124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137349050 | ||||||||
| FaxNumber: | 5137349051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 06/25/2010 | ||||||||
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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 | 363L00000X | 209003647 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 11508-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 200465170 | 05 | IN | MEDICAID |