Provider Demographics
NPI:1518324680
Name:PETERSON, SANDRA (RN, LMT)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RN, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:778 CYPRESS TRAILS DR
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34688-9048
Mailing Address - Country:US
Mailing Address - Phone:813-335-0485
Mailing Address - Fax:
Practice Address - Street 1:778 CYPRESS TRAILS DR
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34688-9048
Practice Address - Country:US
Practice Address - Phone:813-335-0485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-20
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA46414163WM1400X
FLRN9168919163WM1400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM1400XNursing Service ProvidersRegistered NurseNurse Massage Therapist (NMT)