Provider Demographics
NPI:1609292119
Name:PETERSON, KEYONAH
Entity Type:Individual
Prefix:MS
First Name:KEYONAH
Middle Name:
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 1:8259 OLDE 8 RD STE 201
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44067-3701
Mailing Address - Country:US
Mailing Address - Phone:330-998-8543
Mailing Address - Fax:
Practice Address - Street 1:8259 OLDE 8 RD STE 201
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:OH
Practice Address - Zip Code:44067-3701
Practice Address - Country:US
Practice Address - Phone:330-998-8543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-07
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide