Provider Demographics
NPI:1639573694
Name:PETERS, KELLEY J (NP)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:J
Last Name:PETERS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1047
Mailing Address - Street 2:107 BUFFALO STREET
Mailing Address - City:ANTWERP
Mailing Address - State:OH
Mailing Address - Zip Code:45813-1047
Mailing Address - Country:US
Mailing Address - Phone:419-258-5641
Mailing Address - Fax:419-258-2711
Practice Address - Street 1:107 BUFFALO STREET
Practice Address - Street 2:
Practice Address - City:ANTWERP
Practice Address - State:OH
Practice Address - Zip Code:45813-1047
Practice Address - Country:US
Practice Address - Phone:419-258-5641
Practice Address - Fax:419-258-2711
Is Sole Proprietor?:No
Enumeration Date:2014-10-20
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28145162A163W00000X
IN71005210A363L00000X
OHCOA16762363L00000X
TN25358363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner