Provider Demographics
NPI:1548535867
Name:PETERSON, LARNETTA RENNE
Entity type:Individual
Prefix:MRS
First Name:LARNETTA
Middle Name:RENNE
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 10970
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33733-0970
Mailing Address - Country:US
Mailing Address - Phone:727-327-7656
Mailing Address - Fax:727-322-2130
Practice Address - Street 1:4050 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33711-1239
Practice Address - Country:US
Practice Address - Phone:727-327-7656
Practice Address - Fax:727-322-2130
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-20
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060381300Medicaid