Provider Demographics
NPI:1144471210
Name:PETERSON, DIANE KATHRYN (NP)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:KATHRYN
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 1:23970 JACARANDA DR
Mailing Address - Street 2:
Mailing Address - City:TEHACHAPI
Mailing Address - State:CA
Mailing Address - Zip Code:93561-8320
Mailing Address - Country:US
Mailing Address - Phone:661-821-3821
Mailing Address - Fax:661-821-1217
Practice Address - Street 1:23970 JACARANDA DR
Practice Address - Street 2:
Practice Address - City:TEHACHAPI
Practice Address - State:CA
Practice Address - Zip Code:93561-8320
Practice Address - Country:US
Practice Address - Phone:661-821-3821
Practice Address - Fax:661-821-1217
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9908363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health