Provider Demographics
NPI:1467644237
Name:PETERSON, CHERYL SUE
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:SUE
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:PO BOX 3868
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92546-3868
Mailing Address - Country:US
Mailing Address - Phone:951-929-1968
Mailing Address - Fax:951-925-5172
Practice Address - Street 1:2100 S STATE ST
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543
Practice Address - Country:US
Practice Address - Phone:951-929-1968
Practice Address - Fax:951-925-5172
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN205888164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse