Healthcare Provider Details

I. General information

NPI: 1265180798
Provider Name (Legal Business Name): KEVIN TYLER PERRY FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2022
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 DIXIE ST STE 320
CARROLLTON GA
30117-3890
US

IV. Provider business mailing address

706 DIXIE ST STE 320
CARROLLTON GA
30117-3890
US

V. Phone/Fax

Practice location:
  • Phone: 770-812-9326
  • Fax: 770-836-9358
Mailing address:
  • Phone: 770-812-9326
  • Fax: 770-836-9358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-NP286692
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: