Healthcare Provider Details

I. General information

NPI: 1942985411
Provider Name (Legal Business Name): PETIA J IVANOFF MSN, FPMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PETIA J GERVAZOVA

II. Dates (important events)

Enumeration Date: 06/21/2023
Last Update Date: 07/09/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 BERRYWOOD DR
COLUMBIA MO
65201-8372
US

IV. Provider business mailing address

2885 W BATTLEFIELD ST
SPRINGFIELD MO
65807-3952
US

V. Phone/Fax

Practice location:
  • Phone: 573-777-8330
  • Fax:
Mailing address:
  • Phone: 417-761-5214
  • Fax: 417-761-5065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2007031329
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2023023158
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: