Provider Demographics
NPI:1467883140
Name:PETERSON, MARCIA R (RN)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:R
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 S HURON ST
Mailing Address - Street 2:
Mailing Address - City:CHEBOYGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49721-2276
Mailing Address - Country:US
Mailing Address - Phone:231-627-5627
Mailing Address - Fax:231-627-5435
Practice Address - Street 1:825 S HURON ST
Practice Address - Street 2:
Practice Address - City:CHEBOYGAN
Practice Address - State:MI
Practice Address - Zip Code:49721-2276
Practice Address - Country:US
Practice Address - Phone:231-627-5627
Practice Address - Fax:231-627-5435
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-06
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704222463163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse