Healthcare Provider Details

I. General information

NPI: 1316857725
Provider Name (Legal Business Name): AMY PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1607 EXECUTIVE AVE
MYRTLE BEACH SC
29577-6501
US

IV. Provider business mailing address

4600 MONTGOMERY RD STE 400
CINCINNATI OH
45212-2600
US

V. Phone/Fax

Practice location:
  • Phone: 843-712-7316
  • Fax: 843-945-1022
Mailing address:
  • Phone: 833-510-4357
  • Fax: 866-460-2997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number53203
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: