Provider Demographics
NPI:1396388500
Name:PETERSON, ER'REAL ROSE MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:ER'REAL
Middle Name:ROSE MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4320 COMMONS DR W UNIT 4102
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-8655
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12470 TELECOM DR STE 100
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33637-0904
Practice Address - Country:US
Practice Address - Phone:813-779-6303
Practice Address - Fax:888-977-1998
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11003381208M00000X, 363L00000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner