Provider Demographics
NPI:1518000694
Name:PETERSON, NICHOLE YVETTE (DC)
Entity Type:Individual
Prefix:DR
First Name:NICHOLE
Middle Name:YVETTE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:NICHOLE
Other - Middle Name:YVETTE
Other - Last Name:HARVEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:2418 ELMCREST LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-4327
Mailing Address - Country:US
Mailing Address - Phone:208-794-1159
Mailing Address - Fax:
Practice Address - Street 1:1080 W BOISE AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3502
Practice Address - Country:US
Practice Address - Phone:208-388-1895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHAI-1227111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor