Provider Demographics
NPI:1457630360
Name:PETERSON, JOY SHONDELL
Entity Type:Individual
Prefix:
First Name:JOY
Middle Name:SHONDELL
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOY
Other - Middle Name:SHONDELL
Other - Last Name:HERRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:934 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-7135
Mailing Address - Country:US
Mailing Address - Phone:801-779-3001
Mailing Address - Fax:
Practice Address - Street 1:2250 N 1700 W
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-1140
Practice Address - Country:US
Practice Address - Phone:801-779-3001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other