Healthcare Provider Details

I. General information

NPI: 1295883742
Provider Name (Legal Business Name): ELLEN TANNER PETERSON RN, CPNP, MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 01/03/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 W MACARTHUR BLVD
OAKLAND CA
94611-5642
US

IV. Provider business mailing address

15 HARTE AVE
SAN RAFAEL CA
94901-5221
US

V. Phone/Fax

Practice location:
  • Phone: 510-752-6779
  • Fax: 510-752-7836
Mailing address:
  • Phone: 415-485-0783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number333228
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: