1629170790 NPI number — MS. ANN RENEE PETERSEN L.P.C.C., N.C.C.

Table of content: MS. ANN RENEE PETERSEN L.P.C.C., N.C.C. (NPI 1629170790)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629170790 NPI number — MS. ANN RENEE PETERSEN L.P.C.C., N.C.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSEN
Provider First Name:
ANN
Provider Middle Name:
RENEE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
L.P.C.C., N.C.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629170790
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3237
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORRALES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87048-3237
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-400-9913
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4686 CORRALES RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORRALES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87048-8610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-400-9913
Provider Business Practice Location Address Fax Number:
505-890-1527
Provider Enumeration Date:
09/01/2006

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: 101YM0800X , with the licence number:  0069062 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 0098101 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 0119911 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 33007829 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 615695 . This is a "VALUE OPTIONS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 613923500 . This is a "OFFICE OF WORKERS' COMPENSATIONS PROGRAMS, FECA, DEPT OF LABOR" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 201-047-937 . This is a "PRESBYTERIAN HEALTH PLANS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 0000036606 . This is a "STATE OF NM, DEPT. OF VOCATIONAL REHAB" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 10012607 . This is a "LOVELACE PROVIDER ID" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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