Provider Demographics
NPI:1225013139
Name:PETERSON, BRENDA LYNNE (CRNP)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:LYNNE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2208 EXECUTIVE DR STE E
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-6603
Mailing Address - Country:US
Mailing Address - Phone:757-826-7516
Mailing Address - Fax:
Practice Address - Street 1:2208 EXECUTIVE DR STE E
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-6603
Practice Address - Country:US
Practice Address - Phone:757-826-7516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAUP006027-B363LF0000X
VA0024167698363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily