Healthcare Provider Details

I. General information

NPI: 1902447998
Provider Name (Legal Business Name): KRYSTAL MARIE PEREA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2019
Last Update Date: 02/24/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2570 N. SWAN ST
SILVER CITY NM
88065
US

IV. Provider business mailing address

PO BOX 379
TYRONE NM
88065-0379
US

V. Phone/Fax

Practice location:
  • Phone: 575-956-2040
  • Fax:
Mailing address:
  • Phone: 575-313-5518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: