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General NPI Number Information
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NPI Number | 1104696384
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Entity Type | Individual
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Provider Name | KARISSA PETERSON
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Gender | Female
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Dates
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Enumeration Date | 01/08/2024
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Last Update Date | 12/17/2024
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Provider Practice Location Address
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Address Line | 4356 MAYNARDVILLE HWY STE 3
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City | MAYNARDVILLE
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State | TN
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Zip | 37807-3646
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Country | US
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Telephone | 865-630-9030
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Fax |
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Provider Business Mailing Address
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Address Line | 1200 CORPORATE DR STE 400
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City | HOOVER
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State | AL
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Zip | 35242-5424
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Country | US
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Telephone | 423-497-0005
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number | 13293
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 15542
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License Number State | TN
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