Provider Demographics
NPI:1477098564
Name:PERONTI, KELLY ROSE (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ROSE
Last Name:PERONTI
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:CLAIRE
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:401 DOUBLETRACE LN
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-1822
Mailing Address - Country:US
Mailing Address - Phone:770-344-7821
Mailing Address - Fax:
Practice Address - Street 1:401 DOUBLETRACE LN
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-1822
Practice Address - Country:US
Practice Address - Phone:770-344-7821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-27
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN199128363LA2100X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program