Provider Demographics
NPI:1528266764
Name:BERKEY, ELIZABETH M (RD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:M
Last Name:BERKEY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11055 TWIN CREEKS CV
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-2204
Practice Address - Country:US
Practice Address - Phone:260-425-6120
Practice Address - Fax:260-425-6115
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1520029133V00000X
IN37002430A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1520029OtherDIETICIAN STATE LICENSE
MI0N99470OtherMEDICARE GROUP PTAN - THREE RIVERS HEALTH
00864485OtherAMERICIAN DIABETIES ASSOC
00864485OtherAMERICIAN DIABETIES ASSOC