Provider Demographics
NPI:1720639701
Name:BERRY, STEPHANIE SHANTE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:SHANTE
Last Name:BERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 BONHOMME AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63105-1911
Mailing Address - Country:US
Mailing Address - Phone:341-797-7136
Mailing Address - Fax:314-786-0588
Practice Address - Street 1:7777 BONHOMME AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63105-1911
Practice Address - Country:US
Practice Address - Phone:341-797-7136
Practice Address - Fax:314-786-0588
Is Sole Proprietor?:No
Enumeration Date:2019-09-22
Last Update Date:2019-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide