Provider Demographics
NPI:1245008648
Name:PETERSON, OLIVIA (STNA)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13205 SVEC AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-4721
Mailing Address - Country:US
Mailing Address - Phone:216-355-3910
Mailing Address - Fax:
Practice Address - Street 1:13205 SVEC AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44120-4721
Practice Address - Country:US
Practice Address - Phone:216-355-3910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401626110314251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health