Provider Demographics
NPI:1932444965
Name:PETERSON, CRYSTAL M (CNM)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1832 MERRIVALE LOOP
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-5215
Mailing Address - Country:US
Mailing Address - Phone:516-528-5779
Mailing Address - Fax:
Practice Address - Street 1:400 CELEBRATION PL
Practice Address - Street 2:
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747-4970
Practice Address - Country:US
Practice Address - Phone:407-975-0406
Practice Address - Fax:407-975-0407
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-03
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11002022363LX0001X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103732800Medicaid