Provider Demographics
NPI:1982868709
Name:PERALTA, NICHOLLE (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLLE
Middle Name:
Last Name:PERALTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8217 W 20TH ST STE C
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-3033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8217 W 20TH ST STE C
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-3033
Practice Address - Country:US
Practice Address - Phone:970-775-8103
Practice Address - Fax:970-775-8103
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00498272084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOAAA0380OtherPTAN