Provider Demographics
NPI:1205246998
Name:PETERSON, TINA ANNE-MARIE (DC)
Entity type:Individual
Prefix:DR
First Name:TINA
Middle Name:ANNE-MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5703 75TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-3603
Mailing Address - Country:US
Mailing Address - Phone:262-697-1363
Mailing Address - Fax:262-697-1388
Practice Address - Street 1:5703 75TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-3603
Practice Address - Country:US
Practice Address - Phone:262-697-1363
Practice Address - Fax:262-697-1388
Is Sole Proprietor?:No
Enumeration Date:2014-05-02
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3711-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor