Provider Demographics
NPI:1720794241
Name:PETERSEN-FOX, AMY JEAN
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JEAN
Last Name:PETERSEN-FOX
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 1:4300 BLANK RD
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-6315
Mailing Address - Country:US
Mailing Address - Phone:707-479-7810
Mailing Address - Fax:
Practice Address - Street 1:653 CANYON RD
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-4331
Practice Address - Country:US
Practice Address - Phone:415-892-1628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist