Healthcare Provider Details

I. General information

NPI: 1669017315
Provider Name (Legal Business Name): TRISH R PETERSON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PATRICIA A PETERSON

II. Dates (important events)

Enumeration Date: 11/15/2019
Last Update Date: 02/26/2026
Certification Date: 02/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 PLAZA DR STE 102
SIKESTON MO
63801-5148
US

IV. Provider business mailing address

1008 N MAIN ST
SIKESTON MO
63801-5044
US

V. Phone/Fax

Practice location:
  • Phone: 573-472-6010
  • Fax: 573-472-6009
Mailing address:
  • Phone: 573-472-7423
  • Fax: 573-472-7475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2019036575
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: