Provider Demographics
NPI:1831854249
Name:BERRIOS, MARY LENNIS (FNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LENNIS
Last Name:BERRIOS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LENNIS
Other - Last Name:BERRIOS AGOSTO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN
Mailing Address - Street 1:14195 PINE LODGE LN
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913-9471
Mailing Address - Country:US
Mailing Address - Phone:239-789-0428
Mailing Address - Fax:
Practice Address - Street 1:8771 WESLEYAN DR APT 1609
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3298
Practice Address - Country:US
Practice Address - Phone:239-789-0428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-02
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11014921363LG0600X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology