Provider Demographics
NPI:1043633217
Name:PETERSON, KAREN RENEE (ND, LAC)
Entity Type:Individual
Prefix:DR
First Name:KAREN
Middle Name:RENEE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:ND, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 841
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-0841
Mailing Address - Country:US
Mailing Address - Phone:503-774-2857
Mailing Address - Fax:
Practice Address - Street 1:102 W RIM RD
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:NM
Practice Address - Zip Code:87517-8099
Practice Address - Country:US
Practice Address - Phone:503-774-2857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-24
Last Update Date:2023-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC164788171100000X
COACU0002826171100000X
OR2017175F00000X
NMND2023-0024175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No171100000XOther Service ProvidersAcupuncturist