Provider Demographics
NPI:1053616292
Name:CANADY, BERENESE (PMHNP, APN-BC)
Entity type:Individual
Prefix:MRS
First Name:BERENESE
Middle Name:
Last Name:CANADY
Suffix:
Gender:
Credentials:PMHNP, APN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3354 FAXON AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38122-3146
Mailing Address - Country:US
Mailing Address - Phone:901-289-7031
Mailing Address - Fax:901-888-4120
Practice Address - Street 1:4646 POPLAR AVE STE 541
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-4446
Practice Address - Country:US
Practice Address - Phone:901-289-9665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-19
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP7769363LP0808X
TN2012002552363LP0808X
TN154316163W00000X
TNAPN16843363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ040115Medicaid