Healthcare Provider Details

I. General information

NPI: 1063014231
Provider Name (Legal Business Name): MICHELLE LEE PETERSON EARHART
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2020
Last Update Date: 11/12/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 E ARROW HWY
POMONA CA
91767-2535
US

IV. Provider business mailing address

831 E ARROW HWY
POMONA CA
91767-2535
US

V. Phone/Fax

Practice location:
  • Phone: 909-398-4383
  • Fax: 909-398-1736
Mailing address:
  • Phone: 909-398-4383
  • Fax: 909-398-1736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: