Provider Demographics
NPI:1881244721
Name:PETERSON, SALLY ERNST
Entity type:Individual
Prefix:DR
First Name:SALLY
Middle Name:ERNST
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 1:3025 MISTY GLEN DR
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-5719
Mailing Address - Country:US
Mailing Address - Phone:530-246-9505
Mailing Address - Fax:
Practice Address - Street 1:3025 MISTY GLEN DR
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-5719
Practice Address - Country:US
Practice Address - Phone:530-246-9505
Practice Address - Fax:530-246-9505
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider