Healthcare Provider Details

I. General information

NPI: 1801603774
Provider Name (Legal Business Name): MRS. AILEEN MARIE PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2024
Last Update Date: 12/14/2024
Certification Date: 12/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 JONATHAN DR
JACKSONVILLE NC
28540-3153
US

IV. Provider business mailing address

202 JONATHAN DR
JACKSONVILLE NC
28540-3153
US

V. Phone/Fax

Practice location:
  • Phone: 910-650-1994
  • Fax:
Mailing address:
  • Phone: 910-650-1994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number11913
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code374K00000X
TaxonomyReligious Nonmedical Practitioner
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: