Healthcare Provider Details

I. General information

NPI: 1396295606
Provider Name (Legal Business Name): KATHRYN PEREA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2016
Last Update Date: 09/29/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 BALBOA CT SE
LOS LUNAS NM
87031-9240
US

IV. Provider business mailing address

1044 BALBOA CT SE
LOS LUNAS NM
87031-9240
US

V. Phone/Fax

Practice location:
  • Phone: 505-966-1306
  • Fax: 505-966-1350
Mailing address:
  • Phone: 505-966-1306
  • Fax: 505-966-1350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR20397
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: