Basic Information
| Provider Information | |||||||||
| NPI: | 1720720097 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | KYLIE | ||||||||
| MiddleName: | BROOKE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 HERMANN PARK CT APT 254 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770212283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4697771163 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6431 FANNIN ST # 5.170 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770301501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135007160 | ||||||||
| FaxNumber: | 7135000648 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2022 | ||||||||
| LastUpdateDate: | 04/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.