Provider Demographics
NPI:1528503695
Name:PETERSON, AMANDA JANE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JANE
Last Name:PETERSON
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 1:1351 W CENTRAL PARK AVE
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52804-1853
Mailing Address - Country:US
Mailing Address - Phone:563-421-1900
Mailing Address - Fax:563-421-1809
Practice Address - Street 1:1351 W CENTRAL PARK AVE
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804-1853
Practice Address - Country:US
Practice Address - Phone:563-421-1900
Practice Address - Fax:563-421-1809
Is Sole Proprietor?:No
Enumeration Date:2016-12-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA132137163W00000X
IL041511033163W00000X
IL209023700363LF0000X, 363LF0000X
IAA165003363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse