=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104280676
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. KIONNA PERRY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2016
-----------------------------------------------------
Last Update Date | 04/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3900 FORD RD 104E
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19131-2039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-921-6624
-----------------------------------------------------
Fax | 215-921-6715
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3979 LANKENAU AVE APT 1
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19131-2808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-324-7807
-----------------------------------------------------
Fax | 215-921-6715
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 372500000X
-----------------------------------------------------
Taxonomy Name | Chore Provider
-----------------------------------------------------
License Number | 28383601
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 372600000X
-----------------------------------------------------
Taxonomy Name | Adult Companion
-----------------------------------------------------
License Number | 28383601
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number | 28383601
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 376J00000X
-----------------------------------------------------
Taxonomy Name | Homemaker
-----------------------------------------------------
License Number | 28383601
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 376K00000X
-----------------------------------------------------
Taxonomy Name | Nurse's Aide
-----------------------------------------------------
License Number | 28383601
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------