=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235953811
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA NICOLE PETERSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2024
-----------------------------------------------------
Last Update Date | 11/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 421 KENWOOD DR APT J
-----------------------------------------------------
City | EUCLID
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44123-2053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-450-0629
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 421 KENWOOD DR APT J
-----------------------------------------------------
City | EUCLID
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44123-2053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-450-0629
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172A00000X
-----------------------------------------------------
Taxonomy Name | Driver
-----------------------------------------------------
License Number | SZ831260
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------