MEDICARE: NIKITA MARIE 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	225700000X	Massage Therapist

General Provider Information

NPI Number	:	1750898011
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NIKITA MARIE PETERSON

Provider Business Mailing Address
First Line	:	PO BOX 202957
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76006-8957
Country	:	US
Telephone Number	:	682-587-4037
Fax Number	:

Provider Business Practice Location Address
First Line	:	5612 SW GREEN OAKS BLVD STE A
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76017-1154
Country	:	US
Telephone Number	:	682-587-4037
Fax Number	:

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

Provider Enumeration Date	:	01/08/2018
Last Update Date	:	02/25/2022

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Directions to “ NIKITA MARIE PETERSON ” Practice Location

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