Provider Demographics
NPI:1114630043
Name:PETERSON, LAURA (PMHNP)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17254 QUIET SONG CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-2964
Mailing Address - Country:US
Mailing Address - Phone:856-655-2336
Mailing Address - Fax:
Practice Address - Street 1:17254 QUIET SONG CT
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77407-2964
Practice Address - Country:US
Practice Address - Phone:856-655-2336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1042715363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health