Provider Demographics
NPI:1740565233
Name:PETERSON, SHAUNA RENEE (DPH)
Entity Type:Individual
Prefix:MRS
First Name:SHAUNA
Middle Name:RENEE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 EVERLEIGH CT
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-7114
Mailing Address - Country:US
Mailing Address - Phone:803-520-8463
Mailing Address - Fax:
Practice Address - Street 1:105 EVERLEIGH CT
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-7114
Practice Address - Country:US
Practice Address - Phone:803-520-8463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-15
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11723183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist