Provider Demographics
NPI:1104166719
Name:PERRY, THERESA M (RNP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:PERRY
Suffix:
Gender:F
Credentials:RNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4204 CANYON CREST RD
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-3718
Mailing Address - Country:US
Mailing Address - Phone:626-798-9557
Mailing Address - Fax:
Practice Address - Street 1:3324 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-2118
Practice Address - Country:US
Practice Address - Phone:323-660-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-18
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN225340363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1433OtherNURSE PRACTITIONER FURNISHING