Provider Demographics
NPI:1497377055
Name:PETERSON, REBECCA (LPN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:297 MOUNTAIN VIEW EST
Mailing Address - Street 2:
Mailing Address - City:CARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37714-3539
Mailing Address - Country:US
Mailing Address - Phone:865-382-2964
Mailing Address - Fax:
Practice Address - Street 1:297 MOUNTAIN VIEW EST
Practice Address - Street 2:
Practice Address - City:CARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37714-3539
Practice Address - Country:US
Practice Address - Phone:865-382-2964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-17
Last Update Date:2020-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPN0000088826164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse