Provider Demographics
NPI:1225345275
Name:PETERSON FAMILY HEALTHCARE
Entity Type:Organization
Organization Name:PETERSON FAMILY HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNA
Authorized Official - Middle Name:B
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:423-341-0629
Mailing Address - Street 1:PO BOX 716
Mailing Address - Street 2:
Mailing Address - City:ERWIN
Mailing Address - State:TN
Mailing Address - Zip Code:37650-0716
Mailing Address - Country:US
Mailing Address - Phone:423-341-0629
Mailing Address - Fax:
Practice Address - Street 1:1201 N MAIN AVE STE 3
Practice Address - Street 2:
Practice Address - City:ERWIN
Practice Address - State:TN
Practice Address - Zip Code:37650-9102
Practice Address - Country:US
Practice Address - Phone:423-341-0629
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN11999363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty