Healthcare Provider Details

I. General information

NPI: 1528986205
Provider Name (Legal Business Name): HEATHER CORRINE PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3057 W CASINO AVE
PHOENIX AZ
85083-5890
US

IV. Provider business mailing address

3057 W CASINO AVE
PHOENIX AZ
85083-5890
US

V. Phone/Fax

Practice location:
  • Phone: 623-224-1303
  • Fax:
Mailing address:
  • Phone: 623-224-1303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number227471
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: