Provider Demographics
NPI:1043752421
Name:PERALTA, DAMARIS (APN)
Entity Type:Individual
Prefix:
First Name:DAMARIS
Middle Name:
Last Name:PERALTA
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2875 W 19TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-3501
Mailing Address - Country:US
Mailing Address - Phone:773-484-1000
Mailing Address - Fax:773-521-0223
Practice Address - Street 1:4177 S ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-1849
Practice Address - Country:US
Practice Address - Phone:773-254-2222
Practice Address - Fax:773-254-8444
Is Sole Proprietor?:No
Enumeration Date:2016-11-16
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL014392116163W00000X
IL209015425363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse