Basic Information
| Provider Information | |||||||||
| NPI: | 1174743728 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | PETERKIN | ||||||||
| FirstName: | PAULINE | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4740 N STATE ROAD 7 | ||||||||
| Address2: | |||||||||
| City: | LAUDERDALE LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333195839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544864005 | ||||||||
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| Practice Location | |||||||||
| Address1: | 330 SW 27TH AVE | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333122051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547914300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2007 | ||||||||
| LastUpdateDate: | 10/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | APRN1473942 | FL | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 363LP0808X | 1473942 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | APRN1473942 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 766721300 | 05 | FL | MEDICAID | 1473942 | 01 | FL | ARNP | OTHER |