Provider Demographics
NPI:1477951291
Name:PETERSON, DANIEL
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2182 ANTRIM DR
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-8438
Mailing Address - Country:US
Mailing Address - Phone:810-813-9882
Mailing Address - Fax:
Practice Address - Street 1:2182 ANTRIM DR
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-8438
Practice Address - Country:US
Practice Address - Phone:810-813-9882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-10
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704205653163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse