Provider Demographics
NPI:1841204005
Name:PETERSON, DEBORAH K (NP)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:K
Last Name:PETERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9100
Mailing Address - Fax:239-343-9108
Practice Address - Street 1:9131 COLLEGE POINTE CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3245
Practice Address - Country:US
Practice Address - Phone:239-343-9100
Practice Address - Fax:239-343-9108
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000238A363LA2200X
FLAPRN11013139363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000650200OtherANTHEM
FL111708600Medicaid
IN000000659437OtherANTHEM
INP00971563OtherRR MEDICARE
IN200956040Medicaid
IN200956040Medicaid
INM400018901Medicare PIN
IN214580NMedicare PIN