Provider Demographics
NPI:1316628480
Name:PETERS, KALEIGH ANN
Entity type:Individual
Prefix:
First Name:KALEIGH
Middle Name:ANN
Last Name:PETERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62044-1506
Mailing Address - Country:US
Mailing Address - Phone:217-883-7852
Mailing Address - Fax:
Practice Address - Street 1:125 PECK SERVICE ROAD
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62026-1506
Practice Address - Country:US
Practice Address - Phone:618-650-5688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2024019208367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program