Provider Demographics
NPI:1902413339
Name:PETERSON, CARROLLYNN CECELIA
Entity Type:Individual
Prefix:
First Name:CARROLLYNN
Middle Name:CECELIA
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 1:43335 KALIFORNSKY BEACH RD
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-8280
Mailing Address - Country:US
Mailing Address - Phone:907-714-6661
Mailing Address - Fax:907-262-6294
Practice Address - Street 1:43335 KALIFORNSKY BEACH RD
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-8280
Practice Address - Country:US
Practice Address - Phone:907-714-6661
Practice Address - Fax:907-262-6294
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist