Provider Demographics
NPI:1073897229
Name:JENKINS-PERESTAM, MICHELLE (RN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:JENKINS-PERESTAM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 SHELDON GUILE BLVD
Mailing Address - Street 2:
Mailing Address - City:OWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13827-1062
Mailing Address - Country:US
Mailing Address - Phone:607-687-6251
Mailing Address - Fax:607-687-6251
Practice Address - Street 1:3 SHELDON GUILE BLVD
Practice Address - Street 2:
Practice Address - City:OWEGO
Practice Address - State:NY
Practice Address - Zip Code:13827-1062
Practice Address - Country:US
Practice Address - Phone:607-687-6251
Practice Address - Fax:607-687-6251
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY432835-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse