Individual
MRS. IDELLA PETERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
RN
Contact information
Practice address
2925 RUSSELL ST, DETROIT, MI 48207-4825
(313) 396-5300
(313) 396-5353
Mailing address
18751 BAINBRIDGE DR, SOUTHFIELD, MI 48076-5313
(248) 941-3965
(248) 723-8589
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
Primary
4704143291
MI
Other
Enumeration date
10/01/2012
Last updated
10/01/2012
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