Provider Demographics
NPI:1023376308
Name:PETERSEN, LORI ANNELLE (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:ANNELLE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 ANGIE ST
Mailing Address - Street 2:
Mailing Address - City:RICEBORO
Mailing Address - State:GA
Mailing Address - Zip Code:31323-3016
Mailing Address - Country:US
Mailing Address - Phone:904-251-5008
Mailing Address - Fax:
Practice Address - Street 1:104 ANGIE ST
Practice Address - Street 2:
Practice Address - City:RICEBORO
Practice Address - State:GA
Practice Address - Zip Code:31323-3016
Practice Address - Country:US
Practice Address - Phone:904-251-5008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9213978163W00000X
GARN168089163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse