Provider Demographics
NPI:1780982165
Name:PETERSON REESE, VICKI LYNN (SRNA)
Entity type:Individual
Prefix:MS
First Name:VICKI
Middle Name:LYNN
Last Name:PETERSON REESE
Suffix:
Gender:F
Credentials:SRNA
Other - Prefix:MS
Other - First Name:VICKI
Other - Middle Name:LYNN
Other - Last Name:PERDUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3851 SW 160TH AVE
Mailing Address - Street 2:APT 302
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-4690
Mailing Address - Country:US
Mailing Address - Phone:305-409-4137
Mailing Address - Fax:
Practice Address - Street 1:3851 SW 160TH AVE
Practice Address - Street 2:APT 302
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-4690
Practice Address - Country:US
Practice Address - Phone:305-409-4137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-08
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9262827390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRN9262827OtherFLORIDA REGISTERED NURSE LICENSE