Provider Demographics
NPI:1770931636
Name:PETERSON-MCLAURN, MAMIE FAITH
Entity type:Individual
Prefix:MRS
First Name:MAMIE
Middle Name:FAITH
Last Name:PETERSON-MCLAURN
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 9251
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208
Mailing Address - Country:US
Mailing Address - Phone:904-662-1155
Mailing Address - Fax:
Practice Address - Street 1:2747 SOPHIA ST
Practice Address - Street 2:
Practice Address - City:JAX
Practice Address - State:FL
Practice Address - Zip Code:32254
Practice Address - Country:US
Practice Address - Phone:904-662-1155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health