Healthcare Provider Details

I. General information

NPI: 1659868560
Provider Name (Legal Business Name): IRIS HAVLINA DONOVAN PETERSEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2018
Last Update Date: 08/08/2021
Certification Date: 08/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3434 12TH AVE NE
OLYMPIA WA
98506-5175
US

IV. Provider business mailing address

3434 12TH AVE NE
OLYMPIA WA
98506-5175
US

V. Phone/Fax

Practice location:
  • Phone: 360-413-8470
  • Fax:
Mailing address:
  • Phone: 360-413-8470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number11405455-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD61140296
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: