Provider Demographics
NPI:1417597089
Name:PETERSON, DARA (RN)
Entity Type:Individual
Prefix:
First Name:DARA
Middle Name:
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 1:8703 N OWASSO EXPY STE R
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-2671
Mailing Address - Country:US
Mailing Address - Phone:918-888-4024
Mailing Address - Fax:918-889-4025
Practice Address - Street 1:8703 N OWASSO EXPY STE R
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-2671
Practice Address - Country:US
Practice Address - Phone:918-888-4024
Practice Address - Fax:918-889-4025
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK126680163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse