Provider Demographics
NPI:1730444910
Name:PETERSON, BONNIE LOUISE
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:LOUISE
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 1:412 LILLY RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5132
Mailing Address - Country:US
Mailing Address - Phone:360-867-2543
Mailing Address - Fax:360-867-2601
Practice Address - Street 1:412 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5132
Practice Address - Country:US
Practice Address - Phone:360-867-2543
Practice Address - Fax:360-867-2601
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00056442163WC0400X, 163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WP0200XNursing Service ProvidersRegistered NursePediatrics