Provider Demographics
NPI:1003950312
Name:PETERSEN, LESLIE ANN
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:ANN
Last Name:PETERSEN
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 1:720 WOOD ST
Mailing Address - Street 2:HUMBOLDT COUNTY MENTAL HEALTH
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-4413
Mailing Address - Country:US
Mailing Address - Phone:707-445-7710
Mailing Address - Fax:707-476-4061
Practice Address - Street 1:720 WOOD ST
Practice Address - Street 2:HUMBOLDT COUNTY MENTAL HEALTH
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-4413
Practice Address - Country:US
Practice Address - Phone:707-445-7710
Practice Address - Fax:707-476-4061
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA775420163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse