Healthcare Provider Details

I. General information

NPI: 1134961113
Provider Name (Legal Business Name): KIERSTAN PERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2024
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 GALISTEO ST
SANTA FE NM
87505-4747
US

IV. Provider business mailing address

552 MARILYN DR
MANDEVILLE LA
70448-4728
US

V. Phone/Fax

Practice location:
  • Phone: 505-984-8313
  • Fax:
Mailing address:
  • Phone: 504-708-2057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246Q00000X
TaxonomyPathology Specialist/Technologist
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSAH-2024-0176
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: