Provider Demographics
NPI:1689637902
Name:PETERS, SHANE C (FNP-BC)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:C
Last Name:PETERS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:SHANE
Other - Middle Name:C
Other - Last Name:BOSSUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:57 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:NANTUCKET
Mailing Address - State:MA
Mailing Address - Zip Code:02554-2799
Mailing Address - Country:US
Mailing Address - Phone:508-228-9053
Mailing Address - Fax:
Practice Address - Street 1:57 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:NANTUCKET
Practice Address - State:MA
Practice Address - Zip Code:02554-2799
Practice Address - Country:US
Practice Address - Phone:508-228-9053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-08
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA252623163W00000X
MARN252623363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse