Provider Demographics
NPI:1205289964
Name:PERRY, NELLY (LMT)
Entity type:Individual
Prefix:
First Name:NELLY
Middle Name:
Last Name:PERRY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12600 SE FREEMAN WAY
Mailing Address - Street 2:UNIT 19
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-4650
Mailing Address - Country:US
Mailing Address - Phone:971-221-4502
Mailing Address - Fax:
Practice Address - Street 1:12600 SE FREEMAN WAY
Practice Address - Street 2:UNIT 19
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-4650
Practice Address - Country:US
Practice Address - Phone:971-221-4502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12277225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist