Provider Demographics
NPI:1346842325
Name:PETERSON, KEVIN JAMES
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JAMES
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 S DEPEYSTER ST APT 201
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-3696
Mailing Address - Country:US
Mailing Address - Phone:330-603-4954
Mailing Address - Fax:
Practice Address - Street 1:345 S DEPEYSTER ST APT 201
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-3696
Practice Address - Country:US
Practice Address - Phone:330-603-4954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0381319374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide