Provider Demographics
NPI:1538660634
Name:BERE, IMMACULATE NYASHA (STNA)
Entity type:Individual
Prefix:MRS
First Name:IMMACULATE
Middle Name:NYASHA
Last Name:BERE
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 CARRINGTON LN
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:45140-7386
Mailing Address - Country:US
Mailing Address - Phone:216-856-3700
Mailing Address - Fax:
Practice Address - Street 1:220 CARRINGTON LN
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:OH
Practice Address - Zip Code:45140-7386
Practice Address - Country:US
Practice Address - Phone:216-856-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-23
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401962790517374U00000X, 376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No376G00000XNursing Service Related ProvidersNursing Home Administrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH401962790517Medicaid