Provider Demographics
NPI:1124314224
Name:DEBERRY, DAWN DENISE (NP)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:DENISE
Last Name:DEBERRY
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 1:12900 PARK PLAZA DR
Mailing Address - Street 2:# 150
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-9329
Mailing Address - Country:US
Mailing Address - Phone:866-646-3553
Mailing Address - Fax:
Practice Address - Street 1:12900 PARK PLAZA DR
Practice Address - Street 2:# 150
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-9329
Practice Address - Country:US
Practice Address - Phone:866-646-3553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-27
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18869363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology