Provider Demographics
NPI:1790710846
Name:PETERSON, ALICIA M (ARNP)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2975 14TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34120-5512
Mailing Address - Country:US
Mailing Address - Phone:239-919-8615
Mailing Address - Fax:
Practice Address - Street 1:2975 14TH AVE NE
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34120-5512
Practice Address - Country:US
Practice Address - Phone:239-919-8615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2015-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9243506363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
S91781Medicare UPIN
000L429ZMedicare ID - Type Unspecified