Provider Demographics
NPI:1699109868
Name:PETERSON, DEBRA THERESA I (LPN)
Entity type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:THERESA
Last Name:PETERSON
Suffix:I
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1359 W DIAMOND AVE
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85120-6377
Mailing Address - Country:US
Mailing Address - Phone:480-275-9774
Mailing Address - Fax:
Practice Address - Street 1:38454 N CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85140-5835
Practice Address - Country:US
Practice Address - Phone:480-882-3520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-23
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP042742164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse