MEDICARE: TYMERRA PETERSON

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	374U00000X	Home Health Aide	2019-00044952	AL

General Provider Information

NPI Number	:	1659921534
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYMERRA PETERSON

Provider Business Mailing Address
First Line	:	309 18TH AVE NW
Second Line	:
City	:	CENTER POINT
State	:	AL
Zip	:	35215-5225
Country	:	US
Telephone Number	:	205-538-5559
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 CHASE CORPORATE DR
Second Line	:
City	:	HOOVER
State	:	AL
Zip	:	35244-1026
Country	:	US
Telephone Number	:	205-747-5014
Fax Number	:

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

Provider Enumeration Date	:	09/12/2019
Last Update Date	:	09/12/2019

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Directions to “ TYMERRA PETERSON ” Practice Location

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