Provider Demographics
NPI:1396367165
Name:PETERMAN, GABRIELLE ANN (NP)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:ANN
Last Name:PETERMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:GABRIELLE
Other - Middle Name:ANN
Other - Last Name:VICKERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1907 W SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901-5148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1907 W SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-5148
Practice Address - Country:US
Practice Address - Phone:765-456-5687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-14
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28204738A163WM0705X
ILF06202925363LF0000X
IN71010863A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily