Provider Demographics
NPI:1548711724
Name:PETERSON, FARRONDA
Entity type:Individual
Prefix:
First Name:FARRONDA
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 1:3230 SPICER AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32735-9017
Mailing Address - Country:US
Mailing Address - Phone:352-702-6360
Mailing Address - Fax:
Practice Address - Street 1:3230 SPICER AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32735-9017
Practice Address - Country:US
Practice Address - Phone:352-702-6360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005563700Medicaid