Healthcare Provider Details

I. General information

NPI: 1992775506
Provider Name (Legal Business Name): JEANNIE MARIE PETERSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 W 32ND ST
JOPLIN MO
64804-3503
US

IV. Provider business mailing address

302 N HOSPITAL DR
GIRARD KS
66743-2000
US

V. Phone/Fax

Practice location:
  • Phone: 417-347-1111
  • Fax:
Mailing address:
  • Phone: 417-347-1078
  • Fax: 417-347-1079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number55028
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: