Provider Demographics
NPI:1073587259
Name:PETERSON, LORI LETITIA (RN)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:LETITIA
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:571 TAMARRON DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-2023
Mailing Address - Country:US
Mailing Address - Phone:719-524-4395
Mailing Address - Fax:719-526-4747
Practice Address - Street 1:1853 OCONNELL BLVD
Practice Address - Street 2:BLDG. 1042
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4055
Practice Address - Country:US
Practice Address - Phone:719-524-4395
Practice Address - Fax:719-526-4747
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO120460163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management