Healthcare Provider Details

I. General information

NPI: 1528621356
Provider Name (Legal Business Name): CAITLIN PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2019
Last Update Date: 04/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 S SPRUCE ST
KENAI AK
99611-7939
US

IV. Provider business mailing address

320 S SPRUCE ST
KENAI AK
99611-7939
US

V. Phone/Fax

Practice location:
  • Phone: 907-283-7635
  • Fax: 907-283-9575
Mailing address:
  • Phone: 907-283-7635
  • Fax: 907-283-9575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: