Healthcare Provider Details

I. General information

NPI: 1053778993
Provider Name (Legal Business Name): KRISTINE A PETERSON RN, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2016
Last Update Date: 01/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 TROUSDALE DR FL 4
BURLINGAME CA
94010-4506
US

IV. Provider business mailing address

577 AIRPORT BLVD STE 300
BURLINGAME CA
94010-2048
US

V. Phone/Fax

Practice location:
  • Phone: 650-652-8500
  • Fax: 650-652-8502
Mailing address:
  • Phone: 650-240-8198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberRN798839
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: