Provider Demographics
NPI:1962624239
Name:PETERSON, ALYSSA MARIE (LAC)
Entity type:Individual
Prefix:MRS
First Name:ALYSSA
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2151 HAMLINE AVE #108
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-4236
Mailing Address - Country:US
Mailing Address - Phone:612-242-9630
Mailing Address - Fax:
Practice Address - Street 1:2151 HAMLINE AVE #108
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4236
Practice Address - Country:US
Practice Address - Phone:612-242-9630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1357171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist