Provider Demographics
NPI:1225623101
Name:PETERSON, BEVERLY A (LNA)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10401 N CAVE CREEK RD LOT 310
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-1601
Mailing Address - Country:US
Mailing Address - Phone:623-221-3625
Mailing Address - Fax:
Practice Address - Street 1:10401 N CAVE CREEK RD LOT 310
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-1601
Practice Address - Country:US
Practice Address - Phone:623-221-3625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLNA1000007648376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty