MEDICARE: MS. GANIELLE MARVA PETERSON ASSISTED LIVING ADMN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376G00000X	Nursing Home Administrator		FL

General Provider Information

NPI Number	:	1285241489
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. GANIELLE MARVA PETERSON ASSISTED LIVING ADMN

Provider Business Mailing Address
First Line	:	2773 SE CLARETON TER
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34952-6621
Country	:	US
Telephone Number	:	954-657-1812
Fax Number	:

Provider Business Practice Location Address
First Line	:	2773 SE CLARETON TER
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34952-6621
Country	:	US
Telephone Number	:	954-657-1812
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2020
Last Update Date	:	09/30/2020

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