MEDICARE: LATRICE PETERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376K00000X	Nurse's Aide
2	374J00000X	Doula

General Provider Information

NPI Number	:	1124714241
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATRICE PETERSON

Provider Business Mailing Address
First Line	:	51000 MOTT RD TRLR 227
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48188-2155
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	51000 MOTT RD TRLR 227
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48188-2155
Country	:	US
Telephone Number	:	734-447-0347
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/12/2023
Last Update Date	:	04/12/2023

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Directions to “ LATRICE PETERSON ” Practice Location

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