Provider Demographics
NPI:1487908547
Name:PETERSEN, AMANDA (CBE)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:CBE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 E MACARTHUR AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-5234
Mailing Address - Country:US
Mailing Address - Phone:309-336-3265
Mailing Address - Fax:309-336-3265
Practice Address - Street 1:103 E MACARTHUR AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-5234
Practice Address - Country:US
Practice Address - Phone:309-336-3265
Practice Address - Fax:309-336-3265
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-28
Last Update Date:2012-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator