Provider Demographics
NPI:1184814527
Name:PETERS, JOANNE GAINES (LPN)
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:GAINES
Last Name:PETERS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:183 DOGWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:WADING RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11792-3004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:114 GREGORY WAY
Practice Address - Street 2:
Practice Address - City:CALVERTON
Practice Address - State:NY
Practice Address - Zip Code:11933-1187
Practice Address - Country:US
Practice Address - Phone:631-929-0009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230855 1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01622839Medicaid