Provider Demographics
NPI:1376208488
Name:PEREZ, CARMEN VANESSA
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:VANESSA
Last Name:PEREZ
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 1:1209 LOGAN DR
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75077-2505
Mailing Address - Country:US
Mailing Address - Phone:469-236-0126
Mailing Address - Fax:
Practice Address - Street 1:1209 LOGAN DR
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75077-2505
Practice Address - Country:US
Practice Address - Phone:469-236-0126
Practice Address - Fax:214-602-5441
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX146809310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility