Provider Demographics
NPI:1225675218
Name:BERRY, KACIE LAUREN BLACKWELL (NP)
Entity type:Individual
Prefix:MRS
First Name:KACIE
Middle Name:LAUREN BLACKWELL
Last Name:BERRY
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 1:213 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROGUE RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97537-9100
Mailing Address - Country:US
Mailing Address - Phone:541-714-5610
Mailing Address - Fax:541-714-5611
Practice Address - Street 1:213 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ROGUE RIVER
Practice Address - State:OR
Practice Address - Zip Code:97537-9100
Practice Address - Country:US
Practice Address - Phone:541-714-5610
Practice Address - Fax:541-714-5611
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-09
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10030427363LP0808X
SC25669363LA2200X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health