Healthcare Provider Details

I. General information

NPI: 1063746733
Provider Name (Legal Business Name): LAUREN PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2009
Last Update Date: 09/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4518 S MANHATTAN AVE
TAMPA FL
33611-2306
US

IV. Provider business mailing address

4518 S MANHATTAN AVE
TAMPA FL
33611-2306
US

V. Phone/Fax

Practice location:
  • Phone: 813-835-4591
  • Fax: 813-832-3427
Mailing address:
  • Phone: 813-835-4591
  • Fax: 813-832-3427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: