Healthcare Provider Details

I. General information

NPI: 1184814527
Provider Name (Legal Business Name): JOANNE GAINES PETERS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 08/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 GREGORY WAY
CALVERTON NY
11933-1187
US

IV. Provider business mailing address

183 DOGWOOD DRIVE
WADING RIVER NY
11792-3004
US

V. Phone/Fax

Practice location:
  • Phone: 631-929-0009
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number230855 1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: