Healthcare Provider Details

I. General information

NPI: 1134283096
Provider Name (Legal Business Name): JANIS PETRIE ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 04/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48844 HIGHWAY 101
BANDON OR
97411-8232
US

IV. Provider business mailing address

48844 HIGHWAY 101
BANDON OR
97411-8232
US

V. Phone/Fax

Practice location:
  • Phone: 541-329-2078
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number200440305RN
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number200450014NP
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number74552
License Number StateKS
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number45275
License Number StateKS
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1335053052
License Number StateKS
# 6
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number201070011CNS-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: