1508924481 NPI number — MRS. MICHELE JENNEFER PETERSON L.M.P.

Table of content: MRS. MICHELE JENNEFER PETERSON L.M.P. (NPI 1508924481)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508924481 NPI number — MRS. MICHELE JENNEFER PETERSON L.M.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
MICHELE
Provider Middle Name:
JENNEFER
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
L.M.P.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PETERSON
Provider Other First Name:
M.J.
Provider Other Middle Name:
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
L.M.P.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1508924481
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
918 SW 314TH PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FEDERAL WAY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98023-4523
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-945-0609
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
34730 PACIFIC HWY S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FEDERAL WAY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98003-6821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-874-0198
Provider Business Practice Location Address Fax Number:
253-874-0408
Provider Enumeration Date:
12/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  MA00022514 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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