Provider Demographics
NPI:1508924481
Name:PETERSON, MICHELE JENNEFER (LMP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:JENNEFER
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:MRS
Other - First Name:M.J.
Other - Middle Name:
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMP
Mailing Address - Street 1:918 SW 314TH PL
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98023-4523
Mailing Address - Country:US
Mailing Address - Phone:253-945-0609
Mailing Address - Fax:
Practice Address - Street 1:34730 PACIFIC HWY S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6821
Practice Address - Country:US
Practice Address - Phone:253-874-0198
Practice Address - Fax:253-874-0408
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022514174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist