Provider Demographics
NPI:1902569874
Name:PETERSON, ANDRE
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2058 AMBER TRL
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4935
Mailing Address - Country:US
Mailing Address - Phone:917-549-6511
Mailing Address - Fax:
Practice Address - Street 1:2855 SUWANEE LAWRENCEVILLE RD
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-3563
Practice Address - Country:US
Practice Address - Phone:770-394-9055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY098977164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse