Provider Demographics
NPI:1386373975
Name:PETERSON, ADRIANE
Entity type:Individual
Prefix:MS
First Name:ADRIANE
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:PO BOX 1640
Mailing Address - Street 2:
Mailing Address - City:WEAVERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96093-1640
Mailing Address - Country:US
Mailing Address - Phone:530-623-1362
Mailing Address - Fax:530-623-1447
Practice Address - Street 1:1450 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEAVERVILLE
Practice Address - State:CA
Practice Address - Zip Code:96093-1099
Practice Address - Country:US
Practice Address - Phone:530-623-1362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA53Medicaid