Provider Demographics
NPI:1104197201
Name:BERRY, GINA SIMONE (MS, RD, CSP)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:SIMONE
Last Name:BERRY
Suffix:
Gender:F
Credentials:MS, RD, CSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 RIESLING ST
Mailing Address - Street 2:
Mailing Address - City:CLOVERDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95425-3669
Mailing Address - Country:US
Mailing Address - Phone:707-536-1555
Mailing Address - Fax:
Practice Address - Street 1:425 RIESLING ST
Practice Address - Street 2:
Practice Address - City:CLOVERDALE
Practice Address - State:CA
Practice Address - Zip Code:95425-3669
Practice Address - Country:US
Practice Address - Phone:707-536-1555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-20
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
00954751133N00000X
CA00954751133NN1002X, 133V00000X, 133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric