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General NPI Number Information
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NPI Number | 1043763386
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Entity Type | Individual
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Provider Name | JEAN MARIE PETERSON AGNP-C
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Gender | Female
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Dates
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Enumeration Date | 08/03/2016
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Last Update Date | 04/06/2017
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Provider Practice Location Address
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Address Line | STONY BROOK MEDICINE HSC DEPT OF UROLOGY ROOM 040 LEVEL 9
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City | STONY BROOK
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State | NY
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Zip | 11794-8093
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Country | US
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Telephone | 631-444-6270
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Fax | 631-444-6204
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Provider Business Mailing Address
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Address Line | 120 DIVISION AVE
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City | WEST SAYVILLE
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State | NY
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Zip | 11796-1303
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Country | US
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Telephone | 631-750-1523
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | 307876
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License Number State | NY
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