Provider Demographics
NPI:1982375317
Name:PETERSON, KYLIE BRIANNE
Entity Type:Individual
Prefix:MRS
First Name:KYLIE
Middle Name:BRIANNE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:KYLIE
Other - Middle Name:BRIANNE
Other - Last Name:KARSTETTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:104 SPINK ST
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-3652
Mailing Address - Country:US
Mailing Address - Phone:330-264-8498
Mailing Address - Fax:330-264-3777
Practice Address - Street 1:104 SPINK ST
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-3652
Practice Address - Country:US
Practice Address - Phone:330-264-8498
Practice Address - Fax:330-264-3777
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-24
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program