Provider Demographics
NPI:1730844960
Name:PETERSON, DESIREE ELISABETH (CPNP-AC)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:ELISABETH
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CPNP-AC
Other - Prefix:
Other - First Name:DESIREE
Other - Middle Name:ELISABETH
Other - Last Name:BARNARD-PETERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 99213
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0213
Mailing Address - Country:US
Mailing Address - Phone:682-885-4446
Mailing Address - Fax:817-810-1396
Practice Address - Street 1:1401 W PULASKI ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2717
Practice Address - Country:US
Practice Address - Phone:682-885-8012
Practice Address - Fax:682-885-8014
Is Sole Proprietor?:No
Enumeration Date:2021-11-02
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1056679363LP0200X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics