Provider Demographics
NPI:1649604190
Name:PERALTA, JILLIAN ALEXA RAE (LPN)
Entity type:Individual
Prefix:MS
First Name:JILLIAN
Middle Name:ALEXA RAE
Last Name:PERALTA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 FEDERAL LN
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-1618
Mailing Address - Country:US
Mailing Address - Phone:646-596-6128
Mailing Address - Fax:
Practice Address - Street 1:48 FEDERAL LN
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-1618
Practice Address - Country:US
Practice Address - Phone:646-596-6128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-01
Last Update Date:2013-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY315188164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse