Healthcare Provider Details

I. General information

NPI: 1467648576
Provider Name (Legal Business Name): KELLY K. PETERSON LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2007
Last Update Date: 09/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 GRAVES AVE
ROSEMEAD CA
91770-3414
US

IV. Provider business mailing address

7600 GRAVES AVE
ROSEMEAD CA
91770-3414
US

V. Phone/Fax

Practice location:
  • Phone: 626-280-6510
  • Fax:
Mailing address:
  • Phone: 626-280-6510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN224351
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: