| NPI | 1104897982 |
|---|---|
| Former Name | KELLY LEANN PETERSON |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 183500000X Pharmacist (Licence: ID P6230) |
| Additional Taxonomies | 183500000X Pharmacist (Licence: MT 4563) |
| 183500000X Pharmacist (Licence: WA PH00050019) | |
| Enumeration Date | 2006-01-30 |
| Last Update Date | 2020-06-24 |