MEDICARE: DONNA PETERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	PN136555MIV	OH
2	163W00000X	Registered Nurse	RN.471224	OH

General Provider Information

NPI Number	:	1497113542
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONNA PETERSON

Provider Business Mailing Address
First Line	:	7232 JUSTIN WAY
Second Line	:
City	:	MENTOR
State	:	OH
Zip	:	44060-4881
Country	:	US
Telephone Number	:	440-578-8200
Fax Number	:

Provider Business Practice Location Address
First Line	:	3001 PROSPECT AVE E
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44115-2609
Country	:	US
Telephone Number	:	440-578-8200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/03/2016
Last Update Date	:	02/10/2025

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Directions to “ DONNA PETERSON ” Practice Location

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