Provider Demographics
NPI:1043666167
Name:PETERSON, JOYCE LEE (06/01/1964)
Entity Type:Individual
Prefix:MRS
First Name:JOYCE
Middle Name:LEE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:06/01/1964
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 EDGELL ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-1716
Mailing Address - Country:US
Mailing Address - Phone:269-637-4823
Mailing Address - Fax:
Practice Address - Street 1:328 EDGELL ST
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-1716
Practice Address - Country:US
Practice Address - Phone:269-637-4823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-07
Last Update Date:2016-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS800362293251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health