Provider Demographics
NPI:1821711771
Name:PETERSON, JA NAE (FNP-C)
Entity Type:Individual
Prefix:
First Name:JA NAE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:MORGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84050-8001
Mailing Address - Country:US
Mailing Address - Phone:801-721-9163
Mailing Address - Fax:
Practice Address - Street 1:188 N STATE ST
Practice Address - Street 2:
Practice Address - City:MORGAN
Practice Address - State:UT
Practice Address - Zip Code:84050-8001
Practice Address - Country:US
Practice Address - Phone:801-721-9163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT214488-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily