Healthcare Provider Details

I. General information

NPI: 1215059753
Provider Name (Legal Business Name): GAYLE MARIE PETERSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8695 SPECTRUM CENTER BLVD
SAN DIEGO CA
92123-1489
US

IV. Provider business mailing address

18160 SENCILLO DR
SAN DIEGO CA
92128-1325
US

V. Phone/Fax

Practice location:
  • Phone: 858-499-5259
  • Fax: 858-499-5317
Mailing address:
  • Phone: 858-451-3787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License Number483597
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: