Provider Demographics
NPI:1750898011
Name:PETERSON, NIKITA MARIE
Entity type:Individual
Prefix:
First Name:NIKITA
Middle Name:MARIE
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:PO BOX 202957
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76006-8957
Mailing Address - Country:US
Mailing Address - Phone:682-587-4037
Mailing Address - Fax:
Practice Address - Street 1:5612 SW GREEN OAKS BLVD STE A
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-1154
Practice Address - Country:US
Practice Address - Phone:682-587-4037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty