Basic Information
| Provider Information | |||||||||
| NPI: | 1295948222 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERS | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | MSN, APRN-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610 9TH AVE | ||||||||
| Address2: | |||||||||
| City: | BRUNSWICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217161828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018347188 | ||||||||
| FaxNumber: | 3018346350 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 9TH AVE | ||||||||
| Address2: | |||||||||
| City: | BRUNSWICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217161828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018347188 | ||||||||
| FaxNumber: | 3018347889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 07/02/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R114413 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 49577 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.