=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043409352
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BOBBIE JO PETERSON NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2007
-----------------------------------------------------
Last Update Date | 02/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10941 RAVEN RIDGE RD SUITE 103
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27614-6487
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-256-0900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5612 BELLA TERRA CT
-----------------------------------------------------
City | WAKE FOREST
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27587-7518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-222-5634
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 128153
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------