Provider Demographics
NPI:1801009709
Name:PETERSEN, BETH ANN
Entity Type:Individual
Prefix:MRS
First Name:BETH
Middle Name:ANN
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 1:1511 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-6915
Mailing Address - Country:US
Mailing Address - Phone:304-615-5116
Mailing Address - Fax:304-485-5132
Practice Address - Street 1:1511 CRESCENT ST
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-6915
Practice Address - Country:US
Practice Address - Phone:304-615-5116
Practice Address - Fax:304-485-5132
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2392656Medicaid