Provider Demographics
NPI:1285241489
Name:PETERSON, GANIELLE MARVA (ASSISTED LIVING ADMN)
Entity type:Individual
Prefix:MS
First Name:GANIELLE
Middle Name:MARVA
Last Name:PETERSON
Suffix:
Gender:F
Credentials:ASSISTED LIVING ADMN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2773 SE CLARETON TER
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-6621
Mailing Address - Country:US
Mailing Address - Phone:954-657-1812
Mailing Address - Fax:
Practice Address - Street 1:2773 SE CLARETON TER
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-6621
Practice Address - Country:US
Practice Address - Phone:954-657-1812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator