Provider Demographics
NPI:1366156853
Name:BERRY, PHYLLIS JEAN
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:JEAN
Last Name:BERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 WELLMEIER AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45410-2726
Mailing Address - Country:US
Mailing Address - Phone:937-750-5825
Mailing Address - Fax:
Practice Address - Street 1:615 WELLMEIER AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45410-2726
Practice Address - Country:US
Practice Address - Phone:937-750-5825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0259953Medicaid