Provider Demographics
NPI:1215487442
Name:PETERSON, KALYN
Entity type:Individual
Prefix:
First Name:KALYN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:293 BENT TREE LN
Mailing Address - Street 2:
Mailing Address - City:HASLET
Mailing Address - State:TX
Mailing Address - Zip Code:76052-3876
Mailing Address - Country:US
Mailing Address - Phone:817-825-8781
Mailing Address - Fax:817-439-1835
Practice Address - Street 1:293 BENT TREE LN
Practice Address - Street 2:
Practice Address - City:HASLET
Practice Address - State:TX
Practice Address - Zip Code:76052-3876
Practice Address - Country:US
Practice Address - Phone:817-825-8781
Practice Address - Fax:817-439-1835
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization