Provider Demographics
NPI:1922750587
Name:PETERSON, ANNELIESE MENDENHALL (CPM, LM)
Entity Type:Individual
Prefix:MS
First Name:ANNELIESE
Middle Name:MENDENHALL
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CPM, LM
Other - Prefix:
Other - First Name:ANNELIESE
Other - Middle Name:MENDENHALL
Other - Last Name:LANGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPM, LM
Mailing Address - Street 1:2120 PACIFIC AVE SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-4753
Mailing Address - Country:US
Mailing Address - Phone:360-459-7222
Mailing Address - Fax:360-459-7223
Practice Address - Street 1:2120 PACIFIC AVE SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-4753
Practice Address - Country:US
Practice Address - Phone:360-459-7222
Practice Address - Fax:360-459-7223
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-24
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMW61242008176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife