Provider Demographics
NPI:1609015544
Name:PETERSON, BRIANNE LUISA (ARNP)
Entity Type:Individual
Prefix:
First Name:BRIANNE
Middle Name:LUISA
Last Name:PETERSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:BRIANNE
Other - Middle Name:LUISA
Other - Last Name:PITTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5220 BELFORT RD STE 130
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6018
Mailing Address - Country:US
Mailing Address - Phone:904-446-3686
Mailing Address - Fax:904-446-3032
Practice Address - Street 1:5220 BELFORT RD STE 130
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6018
Practice Address - Country:US
Practice Address - Phone:904-446-3686
Practice Address - Fax:904-446-3032
Is Sole Proprietor?:No
Enumeration Date:2009-02-17
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP92152092083P0011X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00718850OtherMEDICARE RAILROAD
GA309069419AMedicaid
FL000848800Medicaid
FLBV095ZMedicare PIN