Provider Demographics
NPI:1821192428
Name:PERILLO, ROSEMARIE
Entity Type:Individual
Prefix:
First Name:ROSEMARIE
Middle Name:
Last Name:PERILLO
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:PO BOX 150
Mailing Address - Street 2:
Mailing Address - City:HOLLY
Mailing Address - State:CO
Mailing Address - Zip Code:81047-0150
Mailing Address - Country:US
Mailing Address - Phone:719-537-0712
Mailing Address - Fax:719-537-6284
Practice Address - Street 1:11600 W 2ND PL
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-1527
Practice Address - Country:US
Practice Address - Phone:719-537-0712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO73909367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07739097Medicaid