Healthcare Provider Details

I. General information

NPI: 1639573694
Provider Name (Legal Business Name): KELLEY J PETERS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2014
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 BUFFALO STREET
ANTWERP OH
45813-1047
US

IV. Provider business mailing address

PO BOX 1047 107 BUFFALO STREET
ANTWERP OH
45813-1047
US

V. Phone/Fax

Practice location:
  • Phone: 419-258-5641
  • Fax: 419-258-2711
Mailing address:
  • Phone: 419-258-5641
  • Fax: 419-258-2711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28145162A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71005210A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCOA16762
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number25358
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: