Provider Demographics
NPI:1427355718
Name:PETERSON, ANNIE C
Entity type:Individual
Prefix:MRS
First Name:ANNIE
Middle Name:C
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 1:17930 PARAMOUNT AVE.
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44135-4127
Mailing Address - Country:US
Mailing Address - Phone:216-804-7494
Mailing Address - Fax:
Practice Address - Street 1:17930 PARKMOUNT AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44135-4127
Practice Address - Country:US
Practice Address - Phone:216-362-6074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-22
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
OH401025140110376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No374U00000XNursing Service Related ProvidersHome Health Aide