Provider Demographics
NPI:1588081079
Name:PEREZ, MYRNA R (CDN MPH)
Entity type:Individual
Prefix:MS
First Name:MYRNA
Middle Name:R
Last Name:PEREZ
Suffix:
Gender:F
Credentials:CDN MPH
Other - Prefix:MS
Other - First Name:MYRNA
Other - Middle Name:ROSA
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CDN MPH
Mailing Address - Street 1:90 PHELPS AVE
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-4913
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:90 PHELPS AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-4913
Practice Address - Country:US
Practice Address - Phone:201-290-8926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-24
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005983133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist