Provider Demographics
NPI:1043723273
Name:PETERS, PENNY
Entity Type:Individual
Prefix:MS
First Name:PENNY
Middle Name:
Last Name:PETERS
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 1:1975 MCPHERSON ST STE 2
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-3482
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1975 MCPHERSON
Practice Address - Street 2:STE 2
Practice Address - City:NORTH BEND
Practice Address - State:OR
Practice Address - Zip Code:97459
Practice Address - Country:US
Practice Address - Phone:541-751-2535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-09
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist