Provider Demographics
NPI:1437384252
Name:PERREAULT, JOHN ROBERT (CRNP)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:PERREAULT
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 S GREENE ST # S10D13
Mailing Address - Street 2:UNIVERSITY OF MARYLAND
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1544
Mailing Address - Country:US
Mailing Address - Phone:410-328-1105
Mailing Address - Fax:410-328-8749
Practice Address - Street 1:22 S GREENE ST # S10D13
Practice Address - Street 2:UNIVERSITY OF MARYLAND
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-1105
Practice Address - Fax:410-328-8749
Is Sole Proprietor?:No
Enumeration Date:2009-05-22
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR126543363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health