Healthcare Provider Details

I. General information

NPI: 1689688822
Provider Name (Legal Business Name): PAMELA J PETERSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 ROUTE 25A STE 225
ROCKY POINT NY
11778-8802
US

IV. Provider business mailing address

333 ROUTE 25A STE 225
ROCKY POINT NY
11778-8802
US

V. Phone/Fax

Practice location:
  • Phone: 631-744-0396
  • Fax:
Mailing address:
  • Phone: 631-744-0396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0000X
TaxonomyPain Management Registered Nurse
License Number488967-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: