Provider Demographics
NPI:1104884253
Name:BERRY, JUDITH A (FNP)
Entity type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:A
Last Name:BERRY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:150 E CENTER ST
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606-3700
Mailing Address - Country:US
Mailing Address - Phone:801-374-7011
Mailing Address - Fax:801-374-7009
Practice Address - Street 1:150 E CENTER ST
Practice Address - Street 2:SUITE 1100
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-3700
Practice Address - Country:US
Practice Address - Phone:801-374-7011
Practice Address - Fax:801-374-7009
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT285456-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD5023Medicare UPIN