=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871644583
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICKI JO PETERS NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2007
-----------------------------------------------------
Last Update Date | 12/30/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4378 S DA VINCI WAY
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-884-0110
-----------------------------------------------------
Fax | 208-884-4508
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4378 S DA VINCI WAY
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-884-0110
-----------------------------------------------------
Fax | 208-884-4508
-----------------------------------------------------
=====================================================
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 | NP-783A
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------