Healthcare Provider Details

I. General information

NPI: 1508605577
Provider Name (Legal Business Name): MYRACLE PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MYRACLE THOMPSON

II. Dates (important events)

Enumeration Date: 05/21/2024
Last Update Date: 11/21/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10400 BLACKLICK EASTERN RD
PICKERINGTON OH
43147-8235
US

IV. Provider business mailing address

4113 REDONDA LN
DAYTON OH
45416-1423
US

V. Phone/Fax

Practice location:
  • Phone: 614-726-7359
  • Fax:
Mailing address:
  • Phone: 937-580-7861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: