Provider Demographics
NPI:1831338573
Name:PETERSON, TERESA HERMOSILLO (RN)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:HERMOSILLO
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:
Other - Last Name:HERMOSILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3910 SW COMUS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-7422
Mailing Address - Country:US
Mailing Address - Phone:503-293-4325
Mailing Address - Fax:
Practice Address - Street 1:3910 SW COMUS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-7422
Practice Address - Country:US
Practice Address - Phone:503-293-4325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-19
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200742369RN163W00000X
OR200413013CNA376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No376K00000XNursing Service Related ProvidersNurse's Aide