Basic Information
| Provider Information | |||||||||
| NPI: | 1811983844 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | JANETTE | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2333 KNOB CREEK RD | ||||||||
| Address2: | SUITE 16 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376042007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239750764 | ||||||||
| FaxNumber: | 4239750141 | ||||||||
| Practice Location | |||||||||
| Address1: | 2333 KNOB CREEK RD | ||||||||
| Address2: | SUITE 16 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376042007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239750764 | ||||||||
| FaxNumber: | 4239750141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2005 | ||||||||
| LastUpdateDate: | 02/06/2009 | ||||||||
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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 | 363L00000X | RN100385 APN7001 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 3905357 | 05 | TN | MEDICAID |