Basic Information
| Provider Information | |||||||||
| NPI: | 1538509641 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERRY | ||||||||
| FirstName: | BRENDA | ||||||||
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| Credential: | NP FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 912882 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802912882 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667650909 | ||||||||
| FaxNumber: | 8558568520 | ||||||||
| Practice Location | |||||||||
| Address1: | 353 FAIRMONT BLVD | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577017375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057558222 | ||||||||
| FaxNumber: | 6057194203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2013 | ||||||||
| LastUpdateDate: | 01/09/2019 | ||||||||
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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 | 363LF0000X | CP000796 | SD | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | CP000796 | SD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1538509641 | 05 | SD | MEDICAID | 1538509641 | 05 | CO | MEDICAID | 1471585 | 05 | ND | MEDICAID |