Provider Demographics
NPI:1619211018
Name:PETERSON, INGRID ABBIE (LAC, MSOM)
Entity Type:Individual
Prefix:MS
First Name:INGRID
Middle Name:ABBIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LAC, MSOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2906 LYON ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94123-3226
Mailing Address - Country:US
Mailing Address - Phone:415-441-2401
Mailing Address - Fax:
Practice Address - Street 1:2906 LYON ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94123-3226
Practice Address - Country:US
Practice Address - Phone:415-441-2401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC14919171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist