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General NPI Number Information
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NPI Number | 1225345275
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Entity Type | Organization
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Legal Business Name | PETERSON FAMILY HEALTHCARE
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Dates
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Enumeration Date | 09/10/2010
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Last Update Date | 09/10/2010
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Provider Practice Location Address
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Address Line | 1201 N MAIN AVE STE 3
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City | ERWIN
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State | TN
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Zip | 37650-9102
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Country | US
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Telephone | 423-341-0629
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 716
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City | ERWIN
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State | TN
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Zip | 37650-0716
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Country | US
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Telephone | 423-341-0629
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | SHANNA B PETERSON
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Credential | FNP
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Telephone | 423-341-0629
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | APN11999
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License Number State | TN
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