Provider Demographics
NPI:1578227369
Name:PETERSON, RUBY D
Entity Type:Individual
Prefix:
First Name:RUBY
Middle Name:D
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1646 W 45TH ST APT J353
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208
Mailing Address - Country:US
Mailing Address - Phone:910-463-8615
Mailing Address - Fax:
Practice Address - Street 1:1646 W 45TH ST APT J353
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-6623
Practice Address - Country:US
Practice Address - Phone:910-463-8615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-27
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker