Basic Information
| Provider Information | |||||||||
| NPI: | 1851527022 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERUSKO | ||||||||
| FirstName: | KRISTY | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MSN/FAMILY NURSE PRA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35000 KAISER CT | ||||||||
| Address2: | |||||||||
| City: | WILLOUGHBY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440943382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402694600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6559 WILSON MILLS ROAD | ||||||||
| Address2: | 106A | ||||||||
| City: | MAYFIELD VILLAGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441433433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4404491540 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2009 | ||||||||
| LastUpdateDate: | 10/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 2009002660 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.