Provider Demographics
NPI:1326271214
Name:PETERSON, SANDRA FAE (BS, MNS)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:FAE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:BS, MNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 COLCHESTER DR E
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-8519
Mailing Address - Country:US
Mailing Address - Phone:360-871-2407
Mailing Address - Fax:
Practice Address - Street 1:1200 COLCHESTER DR E
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-8519
Practice Address - Country:US
Practice Address - Phone:360-871-2407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-26
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL 0002518231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist