Healthcare Provider Details

I. General information

NPI: 1245784255
Provider Name (Legal Business Name): JULISSA PEREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2016
Last Update Date: 08/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

192 TOWER DR STE 400
MIDDLETOWN NY
10941-2057
US

IV. Provider business mailing address

5038 PINE RIDGE RD S
EAST STROUDSBURG PA
18302-8668
US

V. Phone/Fax

Practice location:
  • Phone: 845-692-4391
  • Fax:
Mailing address:
  • Phone: 646-548-7383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: