Provider Demographics
NPI:1194199273
Name:PETERS, SHELLY
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:PETERS
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 1:10258 CAREFREE DR
Mailing Address - Street 2:
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92071-1819
Mailing Address - Country:US
Mailing Address - Phone:619-277-9840
Mailing Address - Fax:
Practice Address - Street 1:9750 CUYAMACA ST
Practice Address - Street 2:101
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-2626
Practice Address - Country:US
Practice Address - Phone:619-277-9840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-30
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist