Provider Demographics
NPI:1346559556
Name:VERNON, PETA-GAYE
Entity Type:Individual
Prefix:MRS
First Name:PETA-GAYE
Middle Name:
Last Name:VERNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10120 CALIFORNIA WATERS DR
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-3466
Mailing Address - Country:US
Mailing Address - Phone:619-746-3309
Mailing Address - Fax:
Practice Address - Street 1:1761 HOTEL CIR S
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3318
Practice Address - Country:US
Practice Address - Phone:619-746-3309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9545207Q00000X, 111N00000X, 171000000X, 253Z00000X, 282NW0100X, 363LA2100X, 363LW0102X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No171000000XOther Service ProvidersMilitary Health Care ProviderGroup - Single Specialty
No253Z00000XAgenciesIn Home Supportive Care
No282NW0100XHospitalsGeneral Acute Care HospitalWomen
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program