Provider Demographics
NPI:1790109825
Name:PETERSON, KERRY G (ARNP, FNP-C)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:G
Last Name:PETERSON
Suffix:
Gender:F
Credentials:ARNP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 803
Mailing Address - Street 2:
Mailing Address - City:ELMA
Mailing Address - State:WA
Mailing Address - Zip Code:98541
Mailing Address - Country:US
Mailing Address - Phone:360-482-2851
Mailing Address - Fax:844-315-8572
Practice Address - Street 1:106 N 1ST ST
Practice Address - Street 2:
Practice Address - City:ELMA
Practice Address - State:WA
Practice Address - Zip Code:98541
Practice Address - Country:US
Practice Address - Phone:360-482-2851
Practice Address - Fax:844-315-8272
Is Sole Proprietor?:No
Enumeration Date:2014-02-10
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60443753363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily