Provider Demographics
NPI:1962041632
Name:PETERSON, DEJALYNN DAQUA
Entity Type:Individual
Prefix:
First Name:DEJALYNN
Middle Name:DAQUA
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 1:5250 LIBRARY RD
Mailing Address - Street 2:
Mailing Address - City:BETHEL PARK
Mailing Address - State:PA
Mailing Address - Zip Code:15102-2715
Mailing Address - Country:US
Mailing Address - Phone:412-854-6900
Mailing Address - Fax:
Practice Address - Street 1:5250 LIBRARY RD
Practice Address - Street 2:
Practice Address - City:BETHEL PARK
Practice Address - State:PA
Practice Address - Zip Code:15102-2715
Practice Address - Country:US
Practice Address - Phone:412-854-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-30
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG011984225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist