Healthcare Provider Details

I. General information

NPI: 1114759081
Provider Name (Legal Business Name): CRYSTAL PETERS APRN - FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16538 W 159TH TER
OLATHE KS
66062-3924
US

IV. Provider business mailing address

110 MASTERS WAY
KINGSLAND GA
31548-6790
US

V. Phone/Fax

Practice location:
  • Phone: 913-588-1227
  • Fax:
Mailing address:
  • Phone: 617-412-7237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2025019608
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number53-84539
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN306903
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberRN306903
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: