Provider Demographics
NPI:1932952603
Name:PETERSON, THERESA ANN
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:ANN
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 1:337 GOLD AVE NW APT 3
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-7502
Mailing Address - Country:US
Mailing Address - Phone:616-337-1378
Mailing Address - Fax:
Practice Address - Street 1:337 GOLD AVE NW APT 3
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-7502
Practice Address - Country:US
Practice Address - Phone:616-337-1378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide