Provider Demographics
NPI:1407132897
Name:PETERS, ANGELA SUE (NURSE PRACTITIONER A)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:SUE
Last Name:PETERS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:642 INDIAN RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-3102
Mailing Address - Country:US
Mailing Address - Phone:847-961-2875
Mailing Address - Fax:
Practice Address - Street 1:642 INDIAN RIDGE DR
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002
Practice Address - Country:US
Practice Address - Phone:847-961-2875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-29
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-009096363LA2200X
IL277.000596363LP0808X
WI4674-33363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health