Provider Demographics
NPI:1992824569
Name:PETERSON, CHERYL JO (RN)
Entity Type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:JO
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 W MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:IL
Mailing Address - Zip Code:61410-1021
Mailing Address - Country:US
Mailing Address - Phone:309-221-5094
Mailing Address - Fax:
Practice Address - Street 1:2323 WINDISH DR
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-9780
Practice Address - Country:US
Practice Address - Phone:309-344-2323
Practice Address - Fax:309-344-4391
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL014-226592163W00000X, 163WP0808X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370984175OtherF.I.N. CORP BRIDGEWAY
IL014-226592OtherDEPT PROF. REG