Healthcare Provider Details

I. General information

NPI: 1639849508
Provider Name (Legal Business Name): KRISTIN PERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2021
Last Update Date: 09/14/2021
Certification Date: 08/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5250 CHEROKEE AVE STE 301
ALEXANDRIA VA
22312-2052
US

IV. Provider business mailing address

3030 JEHOSSEE ST APT 104
RALEIGH NC
27616-5936
US

V. Phone/Fax

Practice location:
  • Phone: 703-647-2762
  • Fax:
Mailing address:
  • Phone: 615-557-2509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number0110007981
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: