Provider Demographics
NPI:1831768514
Name:PETERSON, KIA MARIE
Entity type:Individual
Prefix:
First Name:KIA
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:KIA
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:145 RIVERHAVEN DR UNIT 126
Mailing Address - Street 2:
Mailing Address - City:OXON HILL
Mailing Address - State:MD
Mailing Address - Zip Code:20745-1057
Mailing Address - Country:US
Mailing Address - Phone:202-657-1511
Mailing Address - Fax:
Practice Address - Street 1:329 ANACOSTIA RD SE APT L32
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-7112
Practice Address - Country:US
Practice Address - Phone:202-570-3838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant