Provider Demographics
NPI:1770848152
Name:PETERSEN, SHELLEY
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:PETERSEN
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 1:1640 MIDDLE RD
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:NY
Mailing Address - Zip Code:13421-4182
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:138 NORTH COURT STREET
Practice Address - Street 2:
Practice Address - City:WAMPSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13163-0605
Practice Address - Country:US
Practice Address - Phone:315-366-2363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist