Provider Demographics
NPI:1316170921
Name:PETERMAN, JACQUELYN KAY (RN)
Entity type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:KAY
Last Name:PETERMAN
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 1:1129 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601-1369
Mailing Address - Country:US
Mailing Address - Phone:330-428-0166
Mailing Address - Fax:
Practice Address - Street 1:1129 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-1369
Practice Address - Country:US
Practice Address - Phone:330-428-0166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-29
Last Update Date:2009-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN 295226163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse