Provider Demographics
NPI:1275750903
Name:PETERSON, BRENDA JEAN (RN)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:JEAN
Last Name:PETERSON
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 1:4529 CHELSEA CT
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-7309
Mailing Address - Country:US
Mailing Address - Phone:907-364-4449
Mailing Address - Fax:907-463-5868
Practice Address - Street 1:3245 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-7809
Practice Address - Country:US
Practice Address - Phone:907-364-4449
Practice Address - Fax:907-463-5868
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK18515163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse