Provider Demographics
NPI:1376765479
Name:PETERSEN, KRISTIAN LEE (L AC)
Entity Type:Individual
Prefix:
First Name:KRISTIAN
Middle Name:LEE
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 YORKSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-8134
Mailing Address - Country:US
Mailing Address - Phone:910-200-8806
Mailing Address - Fax:
Practice Address - Street 1:109 HINTON AVE STE 10
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-4772
Practice Address - Country:US
Practice Address - Phone:910-200-8806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC317171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist