Provider Demographics
NPI:1154065498
Name:PETERSEN, THERESA ANN (RN)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:PETERSEN
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 1:3387 BARRANCA PKWY
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-8272
Mailing Address - Country:US
Mailing Address - Phone:949-936-7515
Mailing Address - Fax:949-936-7539
Practice Address - Street 1:3387 BARRANCA PKWY
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92606-8272
Practice Address - Country:US
Practice Address - Phone:949-936-7515
Practice Address - Fax:949-936-7539
Is Sole Proprietor?:No
Enumeration Date:2022-04-22
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA417246163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool