1285241489 NPI number — MS. GANIELLE MARVA PETERSON ASSISTED LIVING ADMN

Table of content: MS. GANIELLE MARVA PETERSON ASSISTED LIVING ADMN (NPI 1285241489)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285241489 NPI number — MS. GANIELLE MARVA PETERSON ASSISTED LIVING ADMN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
GANIELLE
Provider Middle Name:
MARVA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
ASSISTED LIVING ADMN
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:
1285241489
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2773 SE CLARETON TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ST LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34952-6621
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-657-1812
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2773 SE CLARETON TER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT ST LUCIE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34952-6621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-657-1812
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/30/2020

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: 376G00000X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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