Provider Demographics
NPI:1891383287
Name:PETERSON, CAROLYN EVELYN (HOME HEALTH AIDE)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:EVELYN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:HOME HEALTH AIDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3565 STANTON RD SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-2219
Mailing Address - Country:US
Mailing Address - Phone:240-817-7259
Mailing Address - Fax:
Practice Address - Street 1:3016 MARTIN LUTHER KINNG JR. AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032
Practice Address - Country:US
Practice Address - Phone:202-373-0330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-01
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA15472374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide