Provider Demographics
NPI:1730412172
Name:PEREZ, KELLY SUE (RPA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:SUE
Last Name:PEREZ
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:SUE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5503 S CONGRESS AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:ATLANTIS
Mailing Address - State:FL
Mailing Address - Zip Code:33462-6626
Mailing Address - Country:US
Mailing Address - Phone:561-964-1632
Mailing Address - Fax:561-964-1636
Practice Address - Street 1:5503 S CONGRESS AVE STE 206
Practice Address - Street 2:
Practice Address - City:ATLANTIS
Practice Address - State:FL
Practice Address - Zip Code:33462-6626
Practice Address - Country:US
Practice Address - Phone:561-964-1632
Practice Address - Fax:561-964-1636
Is Sole Proprietor?:No
Enumeration Date:2009-09-17
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055368363AM0700X
FLPA9114802363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical