Healthcare Provider Details

I. General information

NPI: 1073587259
Provider Name (Legal Business Name): LORI LETITIA PETERSON R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1853 OCONNELL BLVD BLDG. 1042
FORT CARSON CO
80913-4055
US

IV. Provider business mailing address

571 TAMARRON DR
COLORADO SPRINGS CO
80919-2023
US

V. Phone/Fax

Practice location:
  • Phone: 719-524-4395
  • Fax: 719-526-4747
Mailing address:
  • Phone: 719-524-4395
  • Fax: 719-526-4747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number120460
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: