Provider Demographics
NPI:1467936286
Name:PETERSON, SHALESTA BRIGHT (BA)
Entity Type:Individual
Prefix:
First Name:SHALESTA
Middle Name:BRIGHT
Last Name:PETERSON
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:SHALESTA
Other - Middle Name:BRIGHT
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:7209 ENGLE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-2238
Mailing Address - Country:US
Mailing Address - Phone:260-484-4600
Mailing Address - Fax:
Practice Address - Street 1:7209 ENGLE RD STE 200
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-2238
Practice Address - Country:US
Practice Address - Phone:260-484-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator