Healthcare Provider Details

I. General information

NPI: 1295236271
Provider Name (Legal Business Name): EMILY JANE PETERSON NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2018
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5741 N 26TH ST
TACOMA WA
98407-2415
US

IV. Provider business mailing address

5741 N 26TH ST
TACOMA WA
98407-2415
US

V. Phone/Fax

Practice location:
  • Phone: 253-756-3737
  • Fax: 253-351-5399
Mailing address:
  • Phone: 253-756-3737
  • Fax: 253-351-5399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF01180808
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP60832759
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: