Provider Demographics
NPI:1134509789
Name:PERRTY, KATHY JEAN (LMT)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:JEAN
Last Name:PERRTY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 MIMS ST
Mailing Address - Street 2:
Mailing Address - City:TRUTH OR CONSEQUENCES
Mailing Address - State:NM
Mailing Address - Zip Code:87901-3376
Mailing Address - Country:US
Mailing Address - Phone:575-894-4325
Mailing Address - Fax:
Practice Address - Street 1:400 MIMS ST
Practice Address - Street 2:
Practice Address - City:TRUTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901-3376
Practice Address - Country:US
Practice Address - Phone:575-894-4325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-08
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5961171W00000X
FLMA 36078171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor