Provider Demographics
NPI:1477076073
Name:PETERSON, KATIE (DNP)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 N MISSOURI AVE
Mailing Address - Street 2:
Mailing Address - City:MARCELINE
Mailing Address - State:MO
Mailing Address - Zip Code:64658-1012
Mailing Address - Country:US
Mailing Address - Phone:660-376-2038
Mailing Address - Fax:660-376-3011
Practice Address - Street 1:1600 N MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:MARCELINE
Practice Address - State:MO
Practice Address - Zip Code:64658-1012
Practice Address - Country:US
Practice Address - Phone:660-376-2038
Practice Address - Fax:660-376-3011
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017021979363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily