Provider Demographics
NPI:1326800913
Name:PERALTA, MICHELL (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:MICHELL
Middle Name:
Last Name:PERALTA
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 WILLIAMS AVE
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01902-1831
Mailing Address - Country:US
Mailing Address - Phone:978-595-6795
Mailing Address - Fax:
Practice Address - Street 1:35 MARKET ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-6245
Practice Address - Country:US
Practice Address - Phone:978-259-1370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-29
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2303567363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health