Provider Demographics
NPI:1306465935
Name:BERETTA, KALLIE CHAPMAN (CRNA)
Entity type:Individual
Prefix:
First Name:KALLIE
Middle Name:CHAPMAN
Last Name:BERETTA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 JASMINE HILL RD
Mailing Address - Street 2:
Mailing Address - City:INDIAN SPRINGS
Mailing Address - State:AL
Mailing Address - Zip Code:35124-3328
Mailing Address - Country:US
Mailing Address - Phone:334-202-5596
Mailing Address - Fax:
Practice Address - Street 1:4401 RIVERCHASE DR
Practice Address - Street 2:
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867-7483
Practice Address - Country:US
Practice Address - Phone:334-732-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-14
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8423336367500000X
SC26463367500000X
MARN2339414367500000X
MTAPRN-195940367500000X
AL1-149837367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110164311AMedicaid