Provider Demographics
NPI:1508322926
Name:PETERSON, GENA SUSAN (FNP-C)
Entity Type:Individual
Prefix:
First Name:GENA
Middle Name:SUSAN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:358 GRIMSLEY RD
Mailing Address - Street 2:
Mailing Address - City:COLQUITT
Mailing Address - State:GA
Mailing Address - Zip Code:39837-7436
Mailing Address - Country:US
Mailing Address - Phone:229-400-1976
Mailing Address - Fax:
Practice Address - Street 1:100 FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:DONALSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:39845-1135
Practice Address - Country:US
Practice Address - Phone:229-524-5217
Practice Address - Fax:229-524-6038
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN123548363LF0000X
GARN126548363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily