Provider Demographics
NPI:1528623501
Name:PEREZ, IVELISSE MARIE
Entity type:Individual
Prefix:
First Name:IVELISSE
Middle Name:MARIE
Last Name:PEREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 TOWNSHIP LINE RD
Mailing Address - Street 2:
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-1933
Mailing Address - Country:US
Mailing Address - Phone:215-470-0062
Mailing Address - Fax:
Practice Address - Street 1:915 TOWNSHIP LINE RD
Practice Address - Street 2:
Practice Address - City:ELKINS PARK
Practice Address - State:PA
Practice Address - Zip Code:19027-1933
Practice Address - Country:US
Practice Address - Phone:215-470-0062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-06
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA83-4587349OtherNON MEDICAL HOME CARE SERVICES