Provider Demographics
NPI:1881147692
Name:PERRY, DERETSA (NP)
Entity type:Individual
Prefix:
First Name:DERETSA
Middle Name:
Last Name:PERRY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N STATE OF FRANKLIN RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6008
Mailing Address - Country:US
Mailing Address - Phone:423-979-6000
Mailing Address - Fax:423-979-6011
Practice Address - Street 1:310 N STATE OF FRANKLIN RD
Practice Address - Street 2:SUITE 400
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6008
Practice Address - Country:US
Practice Address - Phone:423-979-6000
Practice Address - Fax:423-979-6011
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21518363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1881147692Medicaid
TNQ024107Medicaid
VA1881147692Medicaid