Healthcare Provider Details

I. General information

NPI: 1336857283
Provider Name (Legal Business Name): CODY PERRY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2022
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 BILLS BRANCH RD
LOGAN WV
25601-5024
US

IV. Provider business mailing address

135 BILLS BRANCH RD
LOGAN WV
25601-5024
US

V. Phone/Fax

Practice location:
  • Phone: 845-538-3197
  • Fax:
Mailing address:
  • Phone: 845-538-3197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number103026
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number103026
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: