Provider Demographics
NPI:1295948222
Name:PETERS, KELLY JO (MSN, APRN-BC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:PETERS
Suffix:
Gender:F
Credentials:MSN, APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:MD
Mailing Address - Zip Code:21716-1828
Mailing Address - Country:US
Mailing Address - Phone:301-834-7188
Mailing Address - Fax:301-834-6350
Practice Address - Street 1:610 9TH AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:MD
Practice Address - Zip Code:21716-1828
Practice Address - Country:US
Practice Address - Phone:301-834-7188
Practice Address - Fax:301-834-7889
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR114413363LF0000X
WV49577363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
451LMedicare PIN
WVNP24081Medicare PIN
CD8143Medicare PIN
WVNP24082Medicare PIN