Provider Demographics
NPI:1851084909
Name:PETERSON, STEPHANI JO
Entity Type:Individual
Prefix:
First Name:STEPHANI
Middle Name:JO
Last Name:PETERSON
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 1:1733 GORNTO RD STE 102-E
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-8469
Mailing Address - Country:US
Mailing Address - Phone:229-247-4810
Mailing Address - Fax:
Practice Address - Street 1:1733 GORNTO RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-8469
Practice Address - Country:US
Practice Address - Phone:229-247-4810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAHADS001108237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist