Provider Demographics
NPI:1366703019
Name:PETERSON, PHYLLIS G (NP)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:G
Last Name:PETERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 DR. BOWEN ST.
Mailing Address - Street 2:
Mailing Address - City:BELLE CHASSE
Mailing Address - State:LA
Mailing Address - Zip Code:70037
Mailing Address - Country:US
Mailing Address - Phone:504-392-3392
Mailing Address - Fax:504-392-3303
Practice Address - Street 1:103 DR. BOWEN ST.
Practice Address - Street 2:
Practice Address - City:BELLE CHASSE
Practice Address - State:LA
Practice Address - Zip Code:70037
Practice Address - Country:US
Practice Address - Phone:504-392-3392
Practice Address - Fax:504-392-3303
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-30
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2065363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2364693Medicaid
LA2065Other2065