Provider Demographics
NPI:1063202745
Name:BERRY, GEORGETTE D
Entity type:Individual
Prefix:
First Name:GEORGETTE
Middle Name:D
Last Name:BERRY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5966 SHERWOOD PL
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-4089
Mailing Address - Country:US
Mailing Address - Phone:678-275-6314
Mailing Address - Fax:
Practice Address - Street 1:3107 INDIAN COTTON CIRCLE
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294
Practice Address - Country:US
Practice Address - Phone:678-275-6314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-07
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0000000374K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374K00000XNursing Service Related ProvidersReligious Nonmedical PractitionerGroup - Single Specialty