Provider Demographics
NPI:1053641993
Name:PETERSON, MICHELE L (CD)
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5850 CAMERON RUN TER
Mailing Address - Street 2:826
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22303-1860
Mailing Address - Country:US
Mailing Address - Phone:703-350-2056
Mailing Address - Fax:
Practice Address - Street 1:5850 CAMERON RUN TER
Practice Address - Street 2:826
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22303-1860
Practice Address - Country:US
Practice Address - Phone:703-350-2056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-27
Last Update Date:2009-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula