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General NPI Number Information
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NPI Number | 1891458683
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Entity Type | Individual
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Provider Name | REVONDA D PETERSON ARNP
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Gender | Female
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Dates
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Enumeration Date | 10/19/2021
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Last Update Date | 10/19/2021
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Provider Practice Location Address
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Address Line | 5420 CHIQUITA BLVD S APT C
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City | CAPE CORAL
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State | FL
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Zip | 33914-7418
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Country | US
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Telephone | 239-240-0040
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Fax |
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Provider Business Mailing Address
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Address Line | 5420 CHIQUITA BLVD S APT C
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City | CAPE CORAL
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State | FL
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Zip | 33914-7418
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Country | US
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Telephone | 239-240-0040
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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 | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 11015620
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License Number State | FL
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