Provider Demographics
NPI:1245810712
Name:PETERSON, PASSION
Entity type:Individual
Prefix:
First Name:PASSION
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 MEADOWLAKE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-2418
Mailing Address - Country:US
Mailing Address - Phone:843-630-4855
Mailing Address - Fax:843-662-6697
Practice Address - Street 1:432 MEADOWLAKE DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-2418
Practice Address - Country:US
Practice Address - Phone:843-630-4855
Practice Address - Fax:843-662-6697
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No372600000XNursing Service Related ProvidersAdult Companion