Provider Demographics
NPI:1396894762
Name:PETERSEN, JONI (RN)
Entity type:Individual
Prefix:MRS
First Name:JONI
Middle Name:
Last Name:PETERSEN
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 1:8038 LAUREL PARK CIR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92509-4096
Mailing Address - Country:US
Mailing Address - Phone:951-360-1816
Mailing Address - Fax:951-360-1874
Practice Address - Street 1:8038 LAUREL PARK CIR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92509-4096
Practice Address - Country:US
Practice Address - Phone:951-360-1816
Practice Address - Fax:951-360-1874
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA430092163W00000X, 163WC0400X, 163WG0000X, 163WH0200X, 163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered163WC0400XNursing Service ProvidersRegistered NurseCase Management
Not Answered163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Not Answered163WH0200XNursing Service ProvidersRegistered NurseHome Health
Not Answered163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARVN002600Medicaid
CA430092OtherREGISTERED NURSE
CAEPSO14230Medicaid