Provider Demographics
NPI:1497120109
Name:PEREZ, KATHLEEN NICOLE (ATC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:NICOLE
Last Name:PEREZ
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 CLOVERDALE CIR
Mailing Address - Street 2:APT 309
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-4487
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 WALMART DR
Practice Address - Street 2:STE 100
Practice Address - City:SODDY DAISY
Practice Address - State:TN
Practice Address - Zip Code:37379-5022
Practice Address - Country:US
Practice Address - Phone:423-332-9490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-07
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0025612255A2300X
TN18992255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer