Healthcare Provider Details

I. General information

NPI: 1073239232
Provider Name (Legal Business Name): CHRISTINA PETERSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2022
Last Update Date: 10/18/2022
Certification Date: 10/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 15TH AVE SE
PUYALLUP WA
98372-3715
US

IV. Provider business mailing address

2323 7TH ST SE APT G202
PUYALLUP WA
98374-1117
US

V. Phone/Fax

Practice location:
  • Phone: 253-697-4535
  • Fax: 253-697-4535
Mailing address:
  • Phone: 865-244-9736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN60064994
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: