Provider Demographics
NPI:1669248290
Name:PETERSON, AMY LYNN
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:PETERSON
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 1:17119 SAMANTHA RD
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:NE
Mailing Address - Zip Code:68028-7009
Mailing Address - Country:US
Mailing Address - Phone:913-683-8347
Mailing Address - Fax:
Practice Address - Street 1:17119 SAMANTHA RD
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:NE
Practice Address - Zip Code:68028-7009
Practice Address - Country:US
Practice Address - Phone:913-683-8347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-27
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider