Provider Demographics
NPI:1629709936
Name:PETERSON, SALLY GLADYS
Entity Type:Individual
Prefix:MISS
First Name:SALLY
Middle Name:GLADYS
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 1:2515 UNIVERSITY AVE SE APT 101W
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-3257
Mailing Address - Country:US
Mailing Address - Phone:507-481-4649
Mailing Address - Fax:
Practice Address - Street 1:2515 UNIVERSITY AVE SE APT 101W
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-3257
Practice Address - Country:US
Practice Address - Phone:507-481-4649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-19
Last Update Date:2022-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program