Provider Demographics
NPI:1619534633
Name:PETERSON, KATHLEEN LAVONNE
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:LAVONNE
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 1:3810 AMBER ST
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRINGS
Mailing Address - State:NV
Mailing Address - Zip Code:89429-9328
Mailing Address - Country:US
Mailing Address - Phone:775-223-2597
Mailing Address - Fax:
Practice Address - Street 1:343 FAIRVIEW DR STE 101
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89701-5389
Practice Address - Country:US
Practice Address - Phone:775-887-5683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-24
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No372600000XNursing Service Related ProvidersAdult Companion
No372500000XNursing Service Related ProvidersChore Provider
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376J00000XNursing Service Related ProvidersHomemaker