Provider Demographics
NPI:1447926852
Name:PERALTA, BRIEANN
Entity type:Individual
Prefix:
First Name:BRIEANN
Middle Name:
Last Name:PERALTA
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 1:8100 WYOMING BLVD NE STE M4-796
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-1946
Mailing Address - Country:US
Mailing Address - Phone:505-450-2930
Mailing Address - Fax:
Practice Address - Street 1:9833 STONE ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-4416
Practice Address - Country:US
Practice Address - Phone:505-450-2930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-17
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMF08210364363LF0000X
NM65313363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily