Provider Demographics
NPI:1659374130
Name:BERRY, ERICCA S (DNP, CPNP)
Entity type:Individual
Prefix:DR
First Name:ERICCA
Middle Name:S
Last Name:BERRY
Suffix:
Gender:F
Credentials:DNP, CPNP
Other - Prefix:MISS
Other - First Name:ERICCA
Other - Middle Name:S
Other - Last Name:CORNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 1/2 S MERRILL AVE STE 9
Mailing Address - Street 2:
Mailing Address - City:GLENDIVE
Mailing Address - State:MT
Mailing Address - Zip Code:59330-1669
Mailing Address - Country:US
Mailing Address - Phone:406-344-8278
Mailing Address - Fax:
Practice Address - Street 1:100 1/2 S MERRILL AVE STE 9
Practice Address - Street 2:
Practice Address - City:GLENDIVE
Practice Address - State:MT
Practice Address - Zip Code:59330-1669
Practice Address - Country:US
Practice Address - Phone:406-344-8278
Practice Address - Fax:406-831-5449
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2025-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT104569363LP0200X, 208000000X
MO2007020392363LP0200X
TX751749363LP0200X
KS45442363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8K5202OtherMEDICARE