Provider Demographics
NPI:1841677366
Name:PETERSON, SUSAN (RN, PHN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RN, PHN
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 688
Mailing Address - Street 2:
Mailing Address - City:BARROW
Mailing Address - State:AK
Mailing Address - Zip Code:99723-0688
Mailing Address - Country:US
Mailing Address - Phone:360-961-3049
Mailing Address - Fax:907-852-2855
Practice Address - Street 1:579 KINGOSAK STREET
Practice Address - Street 2:
Practice Address - City:BARROW
Practice Address - State:AK
Practice Address - Zip Code:99723
Practice Address - Country:US
Practice Address - Phone:907-852-0270
Practice Address - Fax:907-852-2855
Is Sole Proprietor?:No
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60210392163W00000X
AK34747163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163W00000XNursing Service ProvidersRegistered Nurse