Healthcare Provider Details

I. General information

NPI: 1669917985
Provider Name (Legal Business Name): KELLY PERDOMO NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY VANESSA PERDOMO NP-C

II. Dates (important events)

Enumeration Date: 12/21/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3369 BUFORD HWY NE STE 810
BROOKHAVEN GA
30329-3722
US

IV. Provider business mailing address

3369 BUFORD HWY STE 810
BROOKHAVEN GA
30329
US

V. Phone/Fax

Practice location:
  • Phone: 404-321-4692
  • Fax: 404-321-4366
Mailing address:
  • Phone: 404-321-4692
  • Fax: 404-321-4366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN222479
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: