Provider Demographics
NPI:1902668213
Name:BERRY, HEATHER (FNP STUDENT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:FNP STUDENT
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 1:50825 NORTHSTAR WAY
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-6867
Mailing Address - Country:US
Mailing Address - Phone:313-574-0142
Mailing Address - Fax:
Practice Address - Street 1:50825 NORTHSTAR WAY
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48168-6867
Practice Address - Country:US
Practice Address - Phone:313-574-0142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-23
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704291890390200000X
MI4707291890363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program