Provider Demographics
NPI:1295883742
Name:PETERSON, ELLEN TANNER (RN, CPNP, MSN)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:TANNER
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RN, CPNP, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 HARTE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-5221
Mailing Address - Country:US
Mailing Address - Phone:415-485-0783
Mailing Address - Fax:
Practice Address - Street 1:280 W MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5642
Practice Address - Country:US
Practice Address - Phone:510-752-6779
Practice Address - Fax:510-752-7836
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA333228363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics