Healthcare Provider Details

I. General information

NPI: 1457790842
Provider Name (Legal Business Name): CARRIE DAWN PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2013
Last Update Date: 08/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 CHANATE RD
SANTA ROSA CA
95404-1707
US

IV. Provider business mailing address

PO BOX 1735
HEALDSBURG CA
95448-1735
US

V. Phone/Fax

Practice location:
  • Phone: 707-565-4700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberASW33005
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: