Provider Demographics
NPI:1174719405
Name:BERRY, HOLLISTER (NP)
Entity type:Individual
Prefix:
First Name:HOLLISTER
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 208237
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06520-8237
Mailing Address - Country:US
Mailing Address - Phone:203-432-0038
Mailing Address - Fax:203-432-1386
Practice Address - Street 1:55 LOCK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-3603
Practice Address - Country:US
Practice Address - Phone:203-432-0038
Practice Address - Fax:203-432-1386
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002743363LA2200X
CT065534163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse