Provider Demographics
NPI:1598640344
Name:BERRY, MICHELLE RENEE (CN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:BERRY
Suffix:
Gender:F
Credentials:CN
Other - Prefix:
Other - First Name:ELLE
Other - Middle Name:
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CN
Mailing Address - Street 1:PO BOX 2721
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-0335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 2721
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-0335
Practice Address - Country:US
Practice Address - Phone:509-540-3159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-11
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANU61192776133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist