Provider Demographics
NPI:1083267959
Name:COMPASSIONATE PSYCHIATRIC NP CARE PLLC
Entity Type:Organization
Organization Name:COMPASSIONATE PSYCHIATRIC NP CARE PLLC
Other - Org Name:SHELLY LYNN PETERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:315-362-2540
Mailing Address - Street 1:5700 W GENESEE ST STE 132
Mailing Address - Street 2:
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-3212
Mailing Address - Country:US
Mailing Address - Phone:315-362-2540
Mailing Address - Fax:315-671-1786
Practice Address - Street 1:5700 W GENESEE ST STE 132
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-3212
Practice Address - Country:US
Practice Address - Phone:315-362-2540
Practice Address - Fax:315-671-1786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-19
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04532216Medicaid
NY1942754015OtherNPI TYPE 1