Provider Demographics
NPI:1902668213
Name:BERRY, HEATHER (FNP)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:TOMMOLINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 FORD PL STE 3A
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3450
Mailing Address - Country:US
Mailing Address - Phone:313-874-4806
Mailing Address - Fax:313-876-1305
Practice Address - Street 1:40777 ANN ARBOR RD E
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-4448
Practice Address - Country:US
Practice Address - Phone:734-928-1600
Practice Address - Fax:734-325-1082
Is Sole Proprietor?:No
Enumeration Date:2024-01-23
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4707291890363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner