Provider Demographics
NPI:1336608330
Name:PERRY, STEPHEN (LPN)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:
Last Name:PERRY
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:MR
Other - First Name:STEPHEN
Other - Middle Name:
Other - Last Name:PERRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:225 LAZY HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-4504
Mailing Address - Country:US
Mailing Address - Phone:631-338-3478
Mailing Address - Fax:
Practice Address - Street 1:225 LAZY HOLLOW LN
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016-4504
Practice Address - Country:US
Practice Address - Phone:631-338-3478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA347C00000X
GALPN088665164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No164W00000XNursing Service ProvidersLicensed Practical Nurse