Provider Demographics
NPI:1891350989
Name:PETERSON, LOUISA
Entity Type:Individual
Prefix:
First Name:LOUISA
Middle Name:
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 1:3005 SHADY GARDEN CT
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-3508
Mailing Address - Country:US
Mailing Address - Phone:775-910-8003
Mailing Address - Fax:
Practice Address - Street 1:3005 SHADY GARDEN CT
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-3508
Practice Address - Country:US
Practice Address - Phone:775-910-8003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-05
Last Update Date:2019-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV172A00000X
NVNV20181835448172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver