Provider Demographics
NPI:1245857952
Name:TIMOFEENKO PETERSEN, LIDIA
Entity type:Individual
Prefix:
First Name:LIDIA
Middle Name:
Last Name:TIMOFEENKO PETERSEN
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 1:972 SUGAR SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89110-2936
Mailing Address - Country:US
Mailing Address - Phone:208-410-3048
Mailing Address - Fax:
Practice Address - Street 1:972 SUGAR SPRINGS DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-2936
Practice Address - Country:US
Practice Address - Phone:208-410-3048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-29
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID53260363LP0808X
IDTEMP53260363LP0808X
NV835379363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health