Healthcare Provider Details

I. General information

NPI: 1992824569
Provider Name (Legal Business Name): CHERYL JO PETERSON R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 04/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 WINDISH DR
GALESBURG IL
61401-9780
US

IV. Provider business mailing address

402 W MEMORIAL DR
ABINGDON IL
61410-1021
US

V. Phone/Fax

Practice location:
  • Phone: 309-344-2323
  • Fax: 309-344-4391
Mailing address:
  • Phone: 309-221-5094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number014-226592
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number014-226592
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number014-226592
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: