Provider Demographics
NPI:1699722959
Name:BERRY, BETHANY RICHARDSON (CNM, MSN, SANE)
Entity type:Individual
Prefix:MS
First Name:BETHANY
Middle Name:RICHARDSON
Last Name:BERRY
Suffix:
Gender:F
Credentials:CNM, MSN, SANE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4320 DIPLOMACY DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5925
Mailing Address - Country:US
Mailing Address - Phone:907-729-8624
Mailing Address - Fax:907-729-8607
Practice Address - Street 1:4320 DIPLOMACY DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5925
Practice Address - Country:US
Practice Address - Phone:907-729-4955
Practice Address - Fax:907-720-3073
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK634367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKNPO238Medicaid
AKNPO238Medicaid