Provider Demographics
NPI:1891458683
Name:PETERSON, REVONDA D (ARNP)
Entity Type:Individual
Prefix:
First Name:REVONDA
Middle Name:D
Last Name:PETERSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:REVONDA
Other - Middle Name:D
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5420 CHIQUITA BLVD S APT C
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-7418
Mailing Address - Country:US
Mailing Address - Phone:239-240-0040
Mailing Address - Fax:
Practice Address - Street 1:5420 CHIQUITA BLVD S APT C
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33914-7418
Practice Address - Country:US
Practice Address - Phone:239-240-0040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11015620363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL03141975Medicaid