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General NPI Number Information
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NPI Number | 1780128249
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Entity Type | Individual
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Provider Name | LORI LYNN PETERSON NURSE PRACTITIONER
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Gender | Female
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Dates
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Enumeration Date | 12/18/2016
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Last Update Date | 06/14/2018
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Provider Practice Location Address
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Address Line | 8805 N TABLER ROAD HEALTH & WELLNESS CLINIC
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City | MORRIS
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State | IL
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Zip | 60450
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Country | US
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Telephone | 815-942-7834
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Fax | 815-942-7834
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Provider Business Mailing Address
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Address Line | 8805 N TABLER ROAD HEALTH & WELLNESS CLINIC
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City | MORRIS
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State | IL
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Zip | 60450
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Country | US
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Telephone | 815-942-7834
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Fax | 713-951-3468
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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 | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 209015226
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License Number State | IL
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