Provider Demographics
NPI:1942627914
Name:PEREZ, KRISTY MARIE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:MARIE
Last Name:PEREZ
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:KRISTY
Other - Middle Name:MARIE
Other - Last Name:GRAVELINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:115 PHELPS ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-1426
Mailing Address - Country:US
Mailing Address - Phone:315-783-5226
Mailing Address - Fax:
Practice Address - Street 1:115 PHELPS ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-1426
Practice Address - Country:US
Practice Address - Phone:315-783-5226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-27
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY288722164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse