Healthcare Provider Details

I. General information

NPI: 1023697299
Provider Name (Legal Business Name): LUCILLE PETERSEN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LUCY PETERSEN CRNA

II. Dates (important events)

Enumeration Date: 04/06/2021
Last Update Date: 04/06/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 MOUNT VERNON AVE
BAKERSFIELD CA
93306
US

IV. Provider business mailing address

5428 COASTAL WIND ST
BAKERSFIELD CA
93312-8226
US

V. Phone/Fax

Practice location:
  • Phone: 661-326-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95001523
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: