Healthcare Provider Details

I. General information

NPI: 1780052381
Provider Name (Legal Business Name): DEBRA PETERS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2015
Last Update Date: 09/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 GREENWOOD AVE
JACKSON MI
49203-4047
US

IV. Provider business mailing address

1200 SYLVAN RD
CHELSEA MI
48118-9797
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-5710
  • Fax:
Mailing address:
  • Phone: 734-646-4883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703102665
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: