Provider Demographics
NPI:1417485590
Name:PETERSEN, ANGELINE M (DPT)
Entity Type:Individual
Prefix:
First Name:ANGELINE
Middle Name:M
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1588 W CAYUSE CREEK DR STE 110
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-4795
Mailing Address - Country:US
Mailing Address - Phone:208-515-7575
Mailing Address - Fax:208-515-7578
Practice Address - Street 1:1588 W CAYUSE CREEK DR STE 110
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-4795
Practice Address - Country:US
Practice Address - Phone:208-515-7575
Practice Address - Fax:208-515-7578
Is Sole Proprietor?:No
Enumeration Date:2017-06-01
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT3198225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPT3198OtherIDAHO LICENSE