Provider Demographics
NPI:1053565366
Name:PEREZ, KELLY JEAN (REGISTERED DIETITIAN)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JEAN
Last Name:PEREZ
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 LILY DR APT 1
Mailing Address - Street 2:
Mailing Address - City:FT WAINWRIGHT
Mailing Address - State:AK
Mailing Address - Zip Code:99703-1531
Mailing Address - Country:US
Mailing Address - Phone:254-495-5506
Mailing Address - Fax:
Practice Address - Street 1:4076 NEELY RD
Practice Address - Street 2:
Practice Address - City:FT. WAINWRIGHT
Practice Address - State:AK
Practice Address - Zip Code:99703
Practice Address - Country:US
Practice Address - Phone:254-495-5506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-13
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL003552133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered