Provider Demographics
NPI:1801603774
Name:PETERSON, AILEEN MARIE
Entity type:Individual
Prefix:MRS
First Name:AILEEN
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 1:202 JONATHAN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-3153
Mailing Address - Country:US
Mailing Address - Phone:910-650-1994
Mailing Address - Fax:
Practice Address - Street 1:202 JONATHAN DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-3153
Practice Address - Country:US
Practice Address - Phone:910-650-1994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-14
Last Update Date:2024-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X, 174N00000X, 175F00000X, 374J00000X, 374K00000X, 176B00000X
NC11913225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No171400000XOther Service ProvidersHealth & Wellness Coach
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
No175F00000XOther Service ProvidersNaturopath
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No374J00000XNursing Service Related ProvidersDoula
No374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner