Provider Demographics
NPI:1215418439
Name:PERRY, ROSLYN RAQUEL (NP)
Entity type:Individual
Prefix:MS
First Name:ROSLYN
Middle Name:RAQUEL
Last Name:PERRY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4213 RITCHIE DR
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-6766
Mailing Address - Country:US
Mailing Address - Phone:901-647-5798
Mailing Address - Fax:
Practice Address - Street 1:4213 RITCHIE DR
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-6766
Practice Address - Country:US
Practice Address - Phone:901-647-5798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-25
Last Update Date:2018-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902858363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily