Provider Demographics
NPI:1659262962
Name:PETERSON, AMY
Entity type:Individual
Prefix:
First Name:AMY
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 1:138 W 800 N APT 1
Mailing Address - Street 2:
Mailing Address - City:SUNSET
Mailing Address - State:UT
Mailing Address - Zip Code:84015-3100
Mailing Address - Country:US
Mailing Address - Phone:385-445-3420
Mailing Address - Fax:
Practice Address - Street 1:5677 S 1475 E STE 1A
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-7003
Practice Address - Country:US
Practice Address - Phone:385-238-4119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-14
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTF24-116303175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist