Provider Demographics
NPI:1003682477
Name:PETERSON, TIARA JANAYE
Entity Type:Individual
Prefix:
First Name:TIARA
Middle Name:JANAYE
Last Name:PETERSON
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 1:2354 SKYLAND PL SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-3411
Mailing Address - Country:US
Mailing Address - Phone:202-904-3185
Mailing Address - Fax:
Practice Address - Street 1:801 PENNSYLVANIA AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20003-2167
Practice Address - Country:US
Practice Address - Phone:202-904-3185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker