Provider Demographics
NPI:1639405434
Name:PETER, JERIANN C (FNP)
Entity Type:Individual
Prefix:
First Name:JERIANN
Middle Name:C
Last Name:PETER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JERIANN
Other - Middle Name:C
Other - Last Name:KLINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1217 IGUANA RD SW
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124
Mailing Address - Country:US
Mailing Address - Phone:505-785-7521
Mailing Address - Fax:629-899-8684
Practice Address - Street 1:7555 ENCHANTED HILLS BLVD NE STE 104
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-8625
Practice Address - Country:US
Practice Address - Phone:505-771-9833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-29
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005021426163W00000X, 363LF0000X, 363LP2300X
NM53068163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1639405434Medicaid
IL1639405434Medicaid
MO1639405434Medicaid