Healthcare Provider Details

I. General information

NPI: 1225623101
Provider Name (Legal Business Name): BEVERLY A PETERSON LNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2021
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10401 N CAVE CREEK RD LOT 310
PHOENIX AZ
85020-1601
US

IV. Provider business mailing address

10401 N CAVE CREEK RD LOT 310
PHOENIX AZ
85020-1601
US

V. Phone/Fax

Practice location:
  • Phone: 623-221-3625
  • Fax:
Mailing address:
  • Phone: 623-221-3625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberLNA1000007648
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: