Provider Demographics
NPI:1306034129
Name:PETERSON, DEBRA JANE (RN)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:JANE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 TUSCANY DR
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-6217
Mailing Address - Country:US
Mailing Address - Phone:224-333-0539
Mailing Address - Fax:224-333-0539
Practice Address - Street 1:50 N WALKUP AVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-4316
Practice Address - Country:US
Practice Address - Phone:815-356-9400
Practice Address - Fax:815-356-9100
Is Sole Proprietor?:No
Enumeration Date:2007-10-05
Last Update Date:2009-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-355979163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse