Provider Demographics
NPI:1548564966
Name:PETERSON, ROSE CHRISTINE (NPP)
Entity Type:Individual
Prefix:MRS
First Name:ROSE
Middle Name:CHRISTINE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:NPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 JENNIFER LN
Mailing Address - Street 2:
Mailing Address - City:MIDDLE ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11953-3005
Mailing Address - Country:US
Mailing Address - Phone:631-504-6487
Mailing Address - Fax:631-504-6487
Practice Address - Street 1:8 JENNIFER LN
Practice Address - Street 2:
Practice Address - City:MIDDLE ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11953-3005
Practice Address - Country:US
Practice Address - Phone:631-504-6487
Practice Address - Fax:631-504-6487
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-28
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400387-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health