Provider Demographics
NPI:1235154766
Name:PETERSON, MARY S (ARNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:S
Last Name:PETERSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 SE 3RD AVE
Mailing Address - Street 2:THIRD FLOOR CBO/PBS
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-2564
Mailing Address - Country:US
Mailing Address - Phone:954-847-4273
Mailing Address - Fax:954-847-4176
Practice Address - Street 1:1625 SE 3RD AVE
Practice Address - Street 2:SUITE 525
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2521
Practice Address - Country:US
Practice Address - Phone:954-355-4975
Practice Address - Fax:954-355-5898
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 2629942363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS87545Medicare UPIN