Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 2019029836 | MO |
NPI | 1003448960 |
---|---|
Provider Name | Amber Dawn Peterson |
First Address | Ozark, MO 65721-5859 |
Second Address | Springfield, MO 65807-5703 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/02/2020 |
Last Update Date | 09/02/2020 |