Provider Demographics
NPI:1992058614
Name:PETERSEN, GRETCHEN KELLEY (RN)
Entity type:Individual
Prefix:MRS
First Name:GRETCHEN
Middle Name:KELLEY
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 37TH AVENUE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403
Mailing Address - Country:US
Mailing Address - Phone:415-710-2297
Mailing Address - Fax:
Practice Address - Street 1:225 37TH AVE.
Practice Address - Street 2:3RD FLOOR
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403
Practice Address - Country:US
Practice Address - Phone:415-710-2297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA663284163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health