Provider Demographics
NPI:1669917985
Name:PERDOMO, KELLY (NP-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PERDOMO
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:VANESSA
Other - Last Name:PERDOMO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP-C
Mailing Address - Street 1:3369 BUFORD HWY
Mailing Address - Street 2:STE 810
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30329
Mailing Address - Country:US
Mailing Address - Phone:404-321-4692
Mailing Address - Fax:404-321-4366
Practice Address - Street 1:3369 BUFORD HWY NE STE 810
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30329-3722
Practice Address - Country:US
Practice Address - Phone:404-321-4692
Practice Address - Fax:404-321-4366
Is Sole Proprietor?:No
Enumeration Date:2016-12-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN222479363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily