Provider Demographics
NPI:1578001038
Name:PETERSON, STORY (AGNP-C)
Entity Type:Individual
Prefix:
First Name:STORY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5514 CORPORATE DR STE 120
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64507-7754
Mailing Address - Country:US
Mailing Address - Phone:816-271-7169
Mailing Address - Fax:816-271-8810
Practice Address - Street 1:5514 CORPORATE DR STE 120
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64507-7754
Practice Address - Country:US
Practice Address - Phone:816-271-7169
Practice Address - Fax:816-271-8810
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-05
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOAG01170222363LA2200X
MO2017013256363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health