Provider Demographics
NPI:1023269016
Name:PETERSON, MARLA JEAN (CRNA)
Entity type:Individual
Prefix:MRS
First Name:MARLA
Middle Name:JEAN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:MARLA
Other - Middle Name:JEAN
Other - Last Name:POKLEMBA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:91 ARTHUR ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06605
Mailing Address - Country:US
Mailing Address - Phone:303-906-3675
Mailing Address - Fax:
Practice Address - Street 1:267 GRANT ST
Practice Address - Street 2:BRIDGEPORT HOSPITAL
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610
Practice Address - Country:US
Practice Address - Phone:203-384-3801
Practice Address - Fax:203-384-4619
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT077722367500000X, 163W00000X
CT080137367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse