Provider Demographics
NPI:1417388844
Name:PETERSON, GISELLE
Entity Type:Individual
Prefix:
First Name:GISELLE
Middle Name:
Last Name:PETERSON
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 1:644 MEAKANU LN APT 1903
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-2945
Mailing Address - Country:US
Mailing Address - Phone:808-283-4047
Mailing Address - Fax:
Practice Address - Street 1:2045 MAIN ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1648
Practice Address - Country:US
Practice Address - Phone:808-283-4047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-11
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI4474225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist