Provider Demographics
NPI:1114411568
Name:PETERSON, NICOLE ARLENE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ARLENE
Last Name:PETERSON
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 1:682 BRIERGATE WAY
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94544-7245
Mailing Address - Country:US
Mailing Address - Phone:510-487-2910
Mailing Address - Fax:
Practice Address - Street 1:682 BRIERGATE WAY
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94544-7245
Practice Address - Country:US
Practice Address - Phone:510-487-2910
Practice Address - Fax:510-487-2016
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA010081ANOtherMEDICAL