Provider Demographics
NPI:1578788816
Name:PETERSON, KELLI ANN (MD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:ANN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:ANN
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:7822 DAVENPORT STREET
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-3629
Mailing Address - Country:US
Mailing Address - Phone:402-391-4855
Mailing Address - Fax:402-391-6818
Practice Address - Street 1:7822 DAVENPORT STREET
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-3629
Practice Address - Country:US
Practice Address - Phone:402-391-4855
Practice Address - Fax:402-391-6818
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE25596207L00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE094951017OtherWPS MEDICARE