Provider Demographics
NPI:1659576833
Name:PETERSON, PENNY LU (RN)
Entity Type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:LU
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3730 STATE ROUTE 21
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14572-9727
Mailing Address - Country:US
Mailing Address - Phone:585-534-5170
Mailing Address - Fax:
Practice Address - Street 1:3730 STATE ROUTE 21
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:NY
Practice Address - Zip Code:14572-9727
Practice Address - Country:US
Practice Address - Phone:585-534-5170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY273148-1163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02682171Medicaid