Provider Demographics
NPI:1376097105
Name:PETERSON, CARISSA (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:CARISSA
Middle Name:
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 1:472 OLD MISSION RD
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-8552
Mailing Address - Country:US
Mailing Address - Phone:386-314-7483
Mailing Address - Fax:
Practice Address - Street 1:109 W KNAPP AVE
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32132-1555
Practice Address - Country:US
Practice Address - Phone:386-957-4100
Practice Address - Fax:386-957-4104
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9249998363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology