Provider Demographics
NPI:1710469119
Name:PEREZ, NICOLE JANAY
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:JANAY
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 1:34 WOODCROSS DR APT 409
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-2359
Mailing Address - Country:US
Mailing Address - Phone:803-331-4028
Mailing Address - Fax:
Practice Address - Street 1:1720 DUTCH FORK RD STE D
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-8871
Practice Address - Country:US
Practice Address - Phone:803-331-4028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8268225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist