Provider Demographics
NPI:1053620666
Name:PETERSON, HOLLY
Entity type:Individual
Prefix:MRS
First Name:HOLLY
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 1:1107 PARK RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-5066
Mailing Address - Country:US
Mailing Address - Phone:517-787-7907
Mailing Address - Fax:
Practice Address - Street 1:1107 PARK RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-5066
Practice Address - Country:US
Practice Address - Phone:517-787-7907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker