Healthcare Provider Details

I. General information

NPI: 1285241489
Provider Name (Legal Business Name): GANIELLE MARVA PETERSON ASSISTED LIVING ADMN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2020
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2773 SE CLARETON TER
PORT ST LUCIE FL
34952-6621
US

IV. Provider business mailing address

2773 SE CLARETON TER
PORT ST LUCIE FL
34952-6621
US

V. Phone/Fax

Practice location:
  • Phone: 954-657-1812
  • Fax:
Mailing address:
  • Phone: 954-657-1812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: