Healthcare Provider Details

I. General information

NPI: 1073483590
Provider Name (Legal Business Name): LEAH PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2025
Last Update Date: 11/10/2025
Certification Date: 11/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 LAKELAND HILLS BLVD
LAKELAND FL
33805-4543
US

IV. Provider business mailing address

1063 SUGARTREE DR S
LAKELAND FL
33813-1867
US

V. Phone/Fax

Practice location:
  • Phone: 863-899-0174
  • Fax:
Mailing address:
  • Phone: 863-899-0174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number9536577
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: