Provider Demographics
NPI:1659773885
Name:PETERSON, PRISCILLA LOUISE (REGISTERED NURSE)
Entity Type:Individual
Prefix:MRS
First Name:PRISCILLA
Middle Name:LOUISE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6813 STATE ROUTE 31
Mailing Address - Street 2:
Mailing Address - City:DURHAMVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13054-3192
Mailing Address - Country:US
Mailing Address - Phone:315-363-4170
Mailing Address - Fax:
Practice Address - Street 1:6813 STATE ROUTE 31
Practice Address - Street 2:
Practice Address - City:DURHAMVILLE
Practice Address - State:NY
Practice Address - Zip Code:13054-3192
Practice Address - Country:US
Practice Address - Phone:315-363-4170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY533383-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse