Provider Demographics
NPI:1699017764
Name:PETERSON, AMY S (IBCLC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:S
Last Name:PETERSON
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 4TH AVE DR
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-2104
Mailing Address - Country:US
Mailing Address - Phone:208-308-1350
Mailing Address - Fax:208-324-9628
Practice Address - Street 1:805 4TH AVE DR
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-2104
Practice Address - Country:US
Practice Address - Phone:208-308-1350
Practice Address - Fax:208-324-9628
Is Sole Proprietor?:No
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101-17560174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN