Provider Demographics
NPI:1114709318
Name:PETERSON, KAMRIE JENIQUE
Entity Type:Individual
Prefix:
First Name:KAMRIE
Middle Name:JENIQUE
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 1:239 MERCER AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-8245
Mailing Address - Country:US
Mailing Address - Phone:937-831-4280
Mailing Address - Fax:
Practice Address - Street 1:239 MERCER AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-8245
Practice Address - Country:US
Practice Address - Phone:937-831-4280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)