Provider Demographics
NPI:1164604039
Name:PETERSON, JANICE R
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:R
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1406
Mailing Address - Street 2:
Mailing Address - City:BROWNING
Mailing Address - State:MT
Mailing Address - Zip Code:59417-1406
Mailing Address - Country:US
Mailing Address - Phone:406-338-6369
Mailing Address - Fax:
Practice Address - Street 1:760 HOSPITAL CIRCLE
Practice Address - Street 2:
Practice Address - City:BROWNING
Practice Address - State:MT
Practice Address - Zip Code:59417-0760
Practice Address - Country:US
Practice Address - Phone:406-338-6369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-03
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR020450163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse