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General NPI Number Information
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NPI Number | 1942321252
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Entity Type | Individual
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Provider Name | JANICE PETERSEN EASTY O.D.
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Gender | Female
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Dates
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Enumeration Date | 04/03/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 7200 HARRISON AVE F35
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City | ROCKFORD
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State | IL
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Zip | 61112-1017
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Country | US
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Telephone | 815-332-8228
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Fax |
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Provider Business Mailing Address
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Address Line | 470 OXFORD LN
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City | CRYSTAL LAKE
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State | IL
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Zip | 60014-5525
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Country | US
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Telephone | 815-459-7519
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Fax | 815-356-8141
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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 | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State | IL
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