Provider Demographics
NPI:1851118277
Name:PETERSON, WANDA J
Entity type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:J
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 1:7637 SWINDON ST
Mailing Address - Street 2:
Mailing Address - City:BLACKLICK
Mailing Address - State:OH
Mailing Address - Zip Code:43004-9531
Mailing Address - Country:US
Mailing Address - Phone:614-955-0406
Mailing Address - Fax:
Practice Address - Street 1:3260 HENDERSON RD STE 20
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-4391
Practice Address - Country:US
Practice Address - Phone:614-701-7085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator