Provider Demographics
NPI:1306184262
Name:PERRY, KENYA
Entity Type:Individual
Prefix:MS
First Name:KENYA
Middle Name:
Last Name:PERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14619 107TH AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11435-5235
Mailing Address - Country:US
Mailing Address - Phone:718-291-6652
Mailing Address - Fax:
Practice Address - Street 1:7000 AUSTIN ST STE 200
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-1022
Practice Address - Country:US
Practice Address - Phone:718-762-7633
Practice Address - Fax:212-679-5894
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-27
Last Update Date:2013-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY666135174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1215KENMedicaid