Provider Demographics
NPI:1669944062
Name:PETERSEN, PERPETUA (CARE COORDINATOR)
Entity type:Individual
Prefix:
First Name:PERPETUA
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:CARE COORDINATOR
Other - Prefix:
Other - First Name:PERPETUA
Other - Middle Name:
Other - Last Name:OBONO EYENE OBONO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:601 NE FLOWER MOUND RD LOT 183
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-7222
Mailing Address - Country:US
Mailing Address - Phone:520-495-8121
Mailing Address - Fax:
Practice Address - Street 1:713 SW C AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-4311
Practice Address - Country:US
Practice Address - Phone:866-926-6552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-23
Last Update Date:2018-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator