Healthcare Provider Details

I. General information

NPI: 1285447284
Provider Name (Legal Business Name): TINA LEA PEREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TINA LEA PEREZ-HERNANDEZ

II. Dates (important events)

Enumeration Date: 01/31/2025
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11812 GOLDEN BLVD APT 904
BELLEVUE NE
68123-3114
US

IV. Provider business mailing address

11812 GOLDEN BLVD APT 904
BELLEVUE NE
68123-3114
US

V. Phone/Fax

Practice location:
  • Phone: 712-899-3042
  • Fax:
Mailing address:
  • Phone: 712-899-3042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number85057
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: