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NPI Code Detail

MEDICARE: WANDA MARIE PETERSON RN

MEDICARE: WANDA MARIE PETERSON RN
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
1163WP0808XPsychiatric/Mental Health Registered NurseRN077378GA

General Provider Information

NPI Number : 1518084060
Entity Type Code : Individual
Provider Name (Legal Business Name) : WANDA MARIE PETERSON RN
Provider Business Mailing Address
First Line : 78 S ELMWOOD ST
Second Line :
City : ROSSVILLE
State : GA
Zip : 30741-6613
Country : US
Telephone Number : 706-861-3387
Fax Number : 706-638-5541
Provider Business Practice Location Address
First Line : 700 CITY HALL DR
Second Line :
City : FT OGLETHORPE
State : GA
Zip : 30742-7802
Country : US
Telephone Number : 706-861-3387
Fax Number : 706-638-5541
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/22/2007
Last Update Date : 07/08/2007

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